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Nov 12 04 02: 53p 916-0-9558 p• 1 <br /> 11/12/2004 15:49 2094609 AGE STOCKTON itaGE 01/01 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Ilii)) iAj(Y1Di V Kul PERMIT SF#:_ --_ _ I <br /> 1 <br /> LICENSER CONTRACTORS DECLARATION ,LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing%181 Section 7000)of Div s on <br /> 3 of the Business and Professions Cade and my license is in full force and effect. <br /> License# '�Z�.C.+r "` �Expiration Date: <br /> l Date. �- I,` �_Contra for. `i — <br /> s ✓ r 1 <br /> Signature ' u- [` f�•j Gt.. %gyp Title: <br /> G <br /> Printed name ,�-� .i`7 r t !i' .^�.f i ...➢ C� _.______ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHEC4 DNE) <br /> _I have and will maintain a certiicata of consent to self-insure for workers'tort pe nsatlon, as provided t.r <br /> by Section 3700 of the Labor Code,for the performance of the work for which hi:permit is issued. <br /> rL I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued.. My workers'ampensaion insurance <br /> tamer and policy numbers are. I <br /> Carrier e �i ?x- 2 c't l.4fti.1)', Policy Number <br /> I certify that in the performance of the work for which this permit is issued,I sMdl got employ any pc Mo I n <br /> any manner so as to become subject to the workers'compensation laws of Ca:if:rnia,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I s call <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 SUSJ ECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES up To ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY"i 1'EES,AND DAMAGES US <br /> PROVIDED FORM SECTION 7706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> j, (_�(eignaturo afC 57 Uconsrd ruUronzW representStat ve), <br /> hereby authorize(print name) int It rt,,T l'c1t"5'ou tx 4!, .4,1io. <br /> to sign this San Joaquin County Well Permit Application on my behalf. i understand this authorization is valid 1 jr <br /> One 11)year and IS limited to the work plan dated on the front page of this application. <br /> 0-29-02 f Ml <br /> F'"D 24-021ml <br /> r✓27 f <br />