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01124/20051 11:23 9158610430 SECOR <br />,W 1(0 o7 - <br />PAGE 02/©2 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Suppieernent <br />JOB ADDRESS: i��Z- 1✓- 6 -ID Mdc, Sire -1- PERMiT 5R#: �?/6 <br />LICENSED CONTRACTORS DECLARATION (LOD) <br />i hereby afnrrn that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Fluslness andel Profceslonnss Cotle and my ilCense is in full force end effect. <br />License #:Q —�-�� Q Expiration Date: Cry <br />Data: _�/, Contractor: _ LC/�� L �`.a�rq T'v�-. <br />Signature; <br />Printed name:/fin /old T r? <br />01 <br />Thio: !/ c e <br />WORKERS' COMPENSATION DrzCLARIATfON <br />I hereby affirm ,,order 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 psrmit is issued, <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for tha performance of the work for which this permit is Issued. My workers' compensation insuranr„p <br />carrier and policy numbers arc., f <br />Carrier: i�� et: a fY Policy Number: <br />Certify that in the performance of the work for which this permit is issued, i shall not employ any person in <br />any monner soae to became subject to the workars' compensation laws of California, and agree that if I <br />should bmcome subject to the workers' compensation provisions of Section 3100 of the I.abor Code, i shall <br />forthwith comply with those provisions. <br />Expiration Date: Signature' { �_ <br />Printed Nama: <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 />($1 00,000), IN ADDITION TO THE COST OP COMPENSATION, INTEREST, ATTORNr-YS FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3700 OF THL LABOR CODE. <br />Au IZATION FOR orl�r>� 7Ho�N G -5i SIGNING PERMIT APPLICATION <br />9natur2 afC-57 11c0nsr+tl authorized rapresantattve), <br />homby authorize (print name)_ <br />t to sign this San Joaquin County Weil Fafrit Application on my behalf, I understand this authorization Is valid for <br />onell j year and to 11nt'iQed tq(A9r"1Y..-.. d � t a,o11t pt'an dateci'on the front page di this applsoatfon. <br />8.x9-021 MI i <br />EN o 29.02-00 t <br />V22104 <br />