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09/12/2007 10:05 209334 • WGR tSOUTHWEST N PAGE 03/03 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Reid Drive at Luce Avenue PERMIT SR#: (1/�at/�7�4 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 <br /> and Professions Code and my license is in full force and effect. <br /> License C A vol384 _ Expiration Date: JcQ IN/T-7- <br /> Sig ature: <br /> Ij7- <br /> Signature: Tkle: 1� <br /> Printed name: 1 L.JIC <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 selfAnsure 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���:��� ��� ))) 1 <br /> Carrier: Policy Number: �/I3 - 1553-1 <br /> -0(o <br /> I 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'compensatiorkprovi 'ons of Sectio 0 of the Labor Code, I shall <br /> forthwith comply with <br /> �thoosse,provisions. <br /> Expiration Date: J oil 1/0 t Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERA E is UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($900,000.1,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. <br /> AUTOR TION FQRJTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, (signature ofCd7 licensed authorized representative), <br /> hereby authorize(print name) Zil/eey <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> 8-29-02/MI <br /> eHD 29.02{)07 <br /> s/21/h1 <br />