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I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS : s230 PACIFIC AVE , STOCKTON PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License #: <br /> C57 - 680227 Exp Date: NOVEMBER 2010 <br /> Date: 09 NOVEMBER 2009 Contractor: ADVANCED GEOENVIRONMENTAL , INC <br /> Signature: Title : VICE PRESIDENT <br /> Print Name: ROBERT MARTY <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations : (check one) <br /> 1 have and will maintain a certificate of consent to self-insure for workers' compensation , as <br /> provided for by section 3700 of the labor Code , for the performance of the work for which this <br /> permit is issued . <br /> xxx I have and will maintain workers' compensation insurance , as required by Section 3700 of the <br /> Labor Code , for the performance of the work for which this permit is issued . My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: TRAVELER ' S CASUALTY INS COPolicy Number: UB333T982 <br /> I certify that in the performance of the work for which this permit is issued , I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisio <br /> Exp. Date: 17 OCTOBER 2010 Signature: <br /> ROBERT M Y <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,0003 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE . <br /> AUTHORIZATION FOR OTHER THAN C -57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) , to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 9129/n2/MI <br /> EH0 29-01 1115N1 WELL PERMIT APP <br />