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01/09/07 10:07 FAX 916 434 4206 PC EXPLORATION 0 002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 4113y SP-V011 L L�Y1 VPJ PERMIT SR#: DO X013(-21 <br /> ISGkfon, rA <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Business and <br /> - Professions Code and my license is in full force and effect. <br /> License#: O bpJ & .1 b Expiration Date: / 6 - 3 / - 0 <br /> Date: t' 7 ( <br /> Contractor: I- C- G x la1-x'1- 0 c, <br /> Signature: Title: D t^� ( �� MA'14 ;2 �r <br /> Printed name: 22Mh P If`l ►'� <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 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 /> XI 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' compensation insurance <br /> carrier and policy numbers arre:: � <br /> Carrier:�'im�'C& t5L t,,v1Uk�Y-y Policy Number: C) °� 3 <br /> I 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 subjectto the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date:`� b7 Signature: <br /> Printed Name: S O V1 VI. e_ r -N' c n <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <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'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 %� ,/� (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) 14't-t I x Ti I 1 0 r d <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> lone(1)year and is limited to the work plan dated on the front page of this application. <br /> B-29-02/MI <br /> EHD 29-02.001 <br /> 6/22/04 \ <br />