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r. /23/2008 03:25 5307873371 VANNUCCI TECHNOLOGIS PAGE 02 <br /> • • <br /> San Joaquin County Environmental Health De�rtment Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 1jVO 6J' ��Ak L I 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#: d 14 -76 O Exp Date: g <br /> Date: 420,o A Contractor: J/,4,o/il e-c, std yp/0 lr�� <br /> Signature: . Title: /9Ld 164 <br /> Print Name: <br /> I 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 /> 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: SAW ('[a4i! -745 .±rrJ Policy Number: <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, t shall forthwith comply with those provisions. <br /> Exp. Date: -01/ _ Signature: <br /> Print Name: X1111 <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 370G OF THE LABOR CODE. <br /> U�HORIPN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> y�..,...v-- (signature of C-S7 licensed authorized representative), <br /> hereby authorize( nt name) `PAQaA ,taAA O 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 /> slx9rosrMl <br /> EH02"1 1115m7 <br /> WELL PERMIT APP <br />