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01/04/10 09:SOAM All Ve 10bandonment 530.644.1439 • p.03 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: _ PERMIT SR#: <br /> LICENSED CONTRACTORS )ECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of ch<pter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. /l <br /> License#i � ExpiraticaData* Q 1- 2Z — <br /> Date:�_ ")o <br /> Contractor: 1 u7''l� ► ha 0-1D ffik, I) <br /> r-.^" Title:WC�\C1 <br /> Signature: �- y,��� 1 '— <br /> Printed name: VZ1 K Y 1,y <br /> WORKERS' COMPENSATI DN 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 /> on <br /> 0 of <br /> have and will <br /> maintain <br /> rof the work for which this permit ts i sued required My workrs'ecolmpensati compensation nsu aLabor <br /> ode, <br /> e <br /> forperformance <br /> carrier and policy numbers are: (� n/ (� <br /> Gamier: \}n -t )d. policy Number: 01 _100Q - - <br /> ---- <br /> C <br /> Uf <br /> I certify that in the performance of the work for which th s 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 p ovisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. ,,_ __. <br /> ,. ._--.- --"`• <br /> ' <br /> Expiration Date: 12 I Zx'1,,1�Signature�,,� - <br /> Printed Name: boa—It- 1q1CVWARNING:FAILURE TO SECURE A <br /> C <br /> AN EMPLOYER O CRIMINAL PENALTIES AND CMCOVERAGE <br /> L FINES l:P TO ONE HUNDRED THOUSAND DOLLARSUBJECT <br /> PROVIDED FOR HE COST <br /> O THE OF COMP ODEON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> ORIN SECTION <br /> AUTHORIZATION FOR OOTHER THAN C!;7 SIGNING PERMIT APPLICATION <br /> -� ' •! ��-- isignature o(C-57 licensed authorized representative), <br /> Ally Colavita <br /> hereby authorize(print name) __. - <br /> to sign this San Joaquin County Well Permit Application on n 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 /> 8-29-021 MI <br /> EHE 29-02-001 <br /> 6/22104 <br />