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_ ; r <br /> San Joaquin County Environmental�H"ealth Department Unit <br /> {I`V Well Permit Application Supplement <br /> JOB ADDRESS: I lv "n �-1 1 !_ ( I iSERMIT SR#: De b d 1 <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 and Professions Code and my license is in full force and effect. <br /> License##: 1 =29 Expiration Date: <br /> Date: 2 _7-Q(o Contractor: W($fid uia.L' <br /> Signature _ f, �,U Title: f ras It e <br /> Printed name:CQyL_1 K/q W oyd L o.wA -- <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: tJ ! ' <br /> Carrier: �T7i�.� `"t'l�l.nc" Policy Number: _c}a o "oR M — A nN <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'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> �' <br /> Expiration Date: Signature:PrintedName: COnGng E. On d uta rd <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370$OF THE LABOR CODE. <br /> /�ss AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I,__li(1)1('il hCI G . u��C�l1,a l�k,l��a signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) Choc ,, 0T NY'OAM <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 /> $-29-021 MI <br /> EHD 29-02-001 <br /> 6122/04 <br />