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I O� 7fYno�7 i U <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: c ti�. 4 , PERMIT SR#: 47 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 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#: 690227 Expiration Date: 11-30-2009 <br /> Date: <br /> 1-24-09 rnntractor: Advanced GeoEnvironmental, Inc. <br /> Signature: _ Title: vice President <br /> Printed name- Robert Marty <br /> WORKERS' 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' cop Sensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X 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. 0 y workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: state Compensation Insurance Fund Policy Number: 1317474 <br /> 1 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: of October zoos Signature: <br /> Printed Name: Robert Marty <br /> WARNING: FAILURE TO SECURE: ORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> E$NMuIMMIIj, IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S ) EES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION PTMiOF THE LABOR CODE„ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> E-signature ofC-RT licensed authorized representative), <br /> hereby authorize Fprint name) <br /> to sign this San Joaquin County Well Permit Application on my behalf„I understand this authorization is valid for <br /> one N year and is limited to the work plan dated on the front page of this application„ <br /> U-09-IND/MI <br /> EHD 29-02-001 <br /> <1111M <br />