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04/25/2002 08:20 GEOL DRILLING 4 19165654356 <br />NO.079 U05 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 3ZGO W. IAA-rY rni P. Lir PERMIT SR#: <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 Professions Code and my license is in full force and effect. <br />License #: .;-' -S S •2--L, ` Expiration Date: © L.• - 5 C, ` L-�, <br />Date: `4 `f Contractor:Cy1,r (�'� <br />Signature - <br />Title: ) r t: 5 c ..:. •� <br />4- <br />�n. f -moi I .t.. �G. Y •. <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_ I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />I have end will malntaln workers' compensation Insurance, as required by Section 3700 of the Labor Code, <br />` or the performance of the work for whiO this permit is Issued. My workers' compensation insurance <br />carrier and policy numbers are: c� <br />Carrier: ,lam '� `� i -� v -S J f eve (C Policy Number; U3�-1 . o <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 became 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 />Data: `r- Z• Signature: <br />Printed Name: kL i'_in.i•l�'� <br />WARNING: FAILUREfiO 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 SE TION 3706 OF THE LABOR CODE. <br />(slgnahiro ofC-57 lieonsod authorized repr©sontativo), <br />hereby authorize (print na <br />to sign this San Joaquin County Well Permit Application on my 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 applicatlon. <br />5-17-2 DOD f MI <br />