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FPOM TEC — Northern Cai ifornia, Inc. (FRO NOV 17 2006 15 :08/$T. 15 :06/No. 6561671821 P _ <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:Lll—vi-i6:'C /lie Lew;5 Only-e,, 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 Division <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License 406SG9, Expiration Date: 53)- A00,4 <br /> Date: IL I4- ZcoO6 Contractor. T E,G c <br /> Signature: lr - Two:_SQ!:)Mtovvlf <br /> Printed name: �co 11 <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affinn 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 370D 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 /> Carrier: S4ccc(e. 1� va Policy Number: I6606g3-a006 <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 /> Expiration Date: Signature: <br /> Printed Name; <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML 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 9706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. -1*k- (signature 01`C57 licensed authorized representative), <br /> hereby authorize(print name) ZAP LroTNle,{L <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authortation 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.W l <br /> &72/04 <br />