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Jui. 11. 100; 1:36NM Advanced GeoEivi ronmental No. 14h P. 3/3 <br />C�f Q �� � I 21 I t >✓P.r�wa� d <br />1SIti 1 r <br />San Joaquin County Environmental Health nAnn~"# I1nit IV Well Permit Application Supplement <br />JOB ADDRESS:_C mid r w� PERMIT SR#: 'vU `v3 <br />Nt �a FRw,vtcl n Ave <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 #: �-j Q:7 Fxiration Date: <br />i <br />Date: b Contractor- <br />Signature•_.��fl :C�'rM �i� 1�/1 �!�►CD�. <br />Printed name: <br />COMPENSATION DECLARATION <br />1 hereby affirm under penalty of perjury one of the following dedarations: (CHECK ONE) <br />I have and wig 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 pemvt is issued. <br />I have and will maintain workers' compensation insurance. as required by Section 3704 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 are: <br />Carrier_ I bpi Policy Number, f� l y C� <br />I certify that in the performance of Ute work for which this permit Is issued, I shall not employ any person in <br />any roamer so as to become subject to the workers' compensation laws of California, and agree That if'l <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'b t!? <br />()�-gnature: <br />Printed Name_ <br />WARNING: FAILMIE TO SECURE WORKERS' COMPENSA OVERAGE IS UNLAWFUL, AND 3NALL 5Ut3JECT <br />AN EMPLOYER TO CRIMIAIAL PENALTIES AND CIVIL FINi=S UP TO ONE HUNDRED THOUSAND DOLLARs <br />($100,0Mh IN ADDITION TO THE COST OF tuPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />,%A/U�THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, ''"awl <br />/-+ wgmture ofCvt <br />7 kensed authorized representative), <br />hereby authorize (print nitre) ji, A C J t 110A /% A /Alii .x r.A J e�)i r. <br />to sign this San Joaquin County Wet) Permit Application on my behaltuunderstand this authorization is Wild to,- <br />one <br />orone (1) Year and is IkTgWd to the work plan dated on the frond page of thig, appaeatlon. <br />5-29-02 ► 101 <br />EHD 29.02,001 <br />0=4 <br />