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OCT-19-2007 15:14 362 8100 , . 916 362 8100 P.03 <br /> W - /�& flb`z1)6� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 201 V' ZS"ktod 7r- PERMIT SRI1: D Z <br /> 031 560a P...� - <br /> 0O LICENSED CONTRACTORS DECLARATIONL( CD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license Is In full force and effect. <br /> License fk D O�? �} Expiration Date: 0 -31 - 01 <br /> Date: I D! l -� Contractor. (1110 D WAIFA D&LLL,.k — CA,L• 42i4 JAJC, <br /> Signature: Cr LaahOrr�� Title: {�2ES t Dt AIT- <br /> Printed name: 001J CIN. t5i WVODW hQ{o <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carver: S 7 A Tt FWD Policy Number: D D Z d Z 3 2-0 07 <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provlslons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 1 0 - Zp0J? Signature: <br /> Printed Name: ( mAI r WG E UrDUD4rJFh2� <br /> WARNING: FAILURE TO SGCURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OT14ER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed luthorized representativel, <br /> hereby authorize(print name) Fr, :5-114,Pj( <br /> to sign this Son Joaquin County weii Permit Application on my behalf. I understand this authorization is valid fur <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> B-29-02 f MI <br /> EHE 29-02-001 <br /> TOTAL P.03 <br />