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I� 2bj2'O0'7 113:39 9166385611 CASCADL: _LLING <br />rivvI £I I: I3H[YJ r,avanceI U e 0 t n V i ronTie ntaI <br />us, <br />PAGE 02/ pu <br />No 109 f'. 2 <br />Ilia <br />San Joaquin County Environmental Health Departm6nt Unit N Well Permit Application $unAlement <br />JOB ADDRESS = 2 / 23 Ll/ e:4 cz J6d4;t PERMIT SR#: - <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7040) of Division <br />3 of the Business and Professions Code and my license Is In full force and effect. <br />License #: ` - � Expiration Date- 1 ` CS <br />Signature: Title: t ( a r�_ <br />Printed name; A6 � -rQll1I � � J► � � � Q <br />WORKERS' COMPENSATION DECLARATION <br />i hereby affirm under penslty of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certificate of consent to self -insure for warkerm' oorn anon, as provided for <br />by Section 3700 of the Labor Code, for the performancb of the work forwhich this permit is Issued. <br />I have and will maintain wQrkers' 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 <br />. policy numbers are:`J <br />Carrier: ir"1 O C7� N 0(+( 0 Ll a Policy Number; � � �� �Q�2 <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 workare' 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 shalt <br />forthwith comply with thoseprovisions. <br />:1 <br />Expiration Date,_ ~7 <br />—0 I Signatum: <br />Printed Name-, ) 6 i if Ran <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVCRAGE IS UNLAWFUL, AND $HALL SUSJECT <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, IMTERIFST, ATTORNEY'S FELS, ANQ DAMAGES AS <br />PROVIDED FOR IN SECTION $706 OF THE LABOR CODE, <br />AUT RIZATION FOR OTHI THAN C-57 SIGNING PERMIT APPLICATION <br />I, ,!signature &C-57 licensed authorized representative), <br />hersby authorize (print name)_L�2611_9 Y �E <br />:o sign this Sats Joaquin County Well Permit ApplIbAtlon on my behalf, I understand this authorization Is vailrf for <br />me (1) year and Is Limited to the work pion dated on the front page of this application. <br />ZHU 2902-001 <br />4M) IAA <br />