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10/12/2005 11:16 5105687;79 VIRONEX PAGE 02 <br /> 7ci Gtr I?-nd 'q��'�� I��q F7dIJFY hFf1TFf^,I-IfJT� parF 07/'610 <br /> San Joaquin County Enviren}m2ntallHealth Department Unit IV Well Permit Application Supplomont <br /> JOB ADDRESS: �Z � N a �0&( , J G� I�f PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed undAr the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Ausiness-and ProfQssions Code and my licence is In full force and effect. <br /> License#: ( C�;Cl °Z--I Expiration Date: 05 - 3l - o-1 <br /> Date. 10 - 1a• O'S Contractor: l r o (1fX <br /> signature: Q�'ctiGz"^� Title: C� (VZQ/1Ct��tr <br /> Printed name; C�! Y 0. culn GLe,h <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 kniorkers'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 Sectlon 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued, hey workers'compensation insurance <br /> carrier and policy nurnt,ers are- <br /> Carrier: NQ f1t �- Polley Number: � t5 k 33 O Z <br /> I certify that in the perFormance of tho worth for which this permit is Issued, I tiIidJl nut employ any person In <br /> any manner so as to become subject to the workers' compen4®tion laws of California, and agree that if I <br /> should beoorne subject to the workers-compensation provisions of Section 3700 of the Labor Code, 1 .€hell <br /> `orthwith comply with those provisions- <br /> Expiration Date:d�'dS' O�0 Signature: <br /> _0j-1V- 2 a -------- <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'CO MPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTERIEST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOIR CODE. <br /> AUTHORIZATION FOR OTNER THAN U-57 SIGNING PERMIT APPLICATION <br /> (signature ofC•57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to Sign thin SAn Jnarluin County Wall PArmlt Applleltivn on my beha'f. I under5k011t lfdu authDrriation fr.VrAlld for <br /> ono(1)year and is limited to the Work plan dated on the front page of this applicetJon, <br /> a-zs-oz t MI <br /> i:HD 25�-02nn r <br /> N22!bd <br />