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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS : 6230 PACIFIC AVE , STOCKTON PERMIT SR # <br /> i <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 /> C57 - 680227 NOVEMBER 2010 <br /> License #: Exp Date : <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 /> I 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 COPollcy 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 NA 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 $1001000, 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 /> I, (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 /> 81291021M1 <br /> EHD 29-01 11/5M7 WELL PERMIT APP <br />