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FRC?1A TEG — hdor th.ern Ga I fior n i a, t <br />(THU) MAY 10 2007 3 : U2%S T. 8 : 02/rd o. 666'1 671 331 R 2 <br />,�f 6 (S- V1 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 3/S' if Cleve,471'7 Si' PERMIT SR#: Ooir4o 7 <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#O6 S6g Expiration Date: <br />Date: 5-0-0 Contractor: IEG-Noel Lo"kC-i4oyv\iCk- <br />Signature; `1ti Title: <br />RMO <br />Printed name: 11CAV' <br />V, <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 are: <br />Carrier: Slo�(��U-Aa Policy Number: g3-�000 <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 subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: ... _........ Signature: <br />Printed Name: <br />NARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />4N 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 />'ROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />—24L (signature ofC-57 licensed authorized representative), <br />rereby authorize (print name) <br />o sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />ne (1) year and is limited to the work plan dated on the front page of this application. <br />-25-021 MI <br />EFiD 29-02-001 <br />