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i4AM //V_ <br />p.l <br />D9383696D �, 2 <br />San Joaquin County Environmental Health Departme Unit IV Well Permit Application Suppleme t <br />JOB ADDRESS: '31.5 F !/ T'f sfrrt f jTy p IT SR#: 6 <br />0o si <br />LICENSED CONTRACTORS DECLARATION (L` G� <br />I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Divislo <br />3 of the Business and Professions Code and my license is in full force and effect <br />License # & Cj C, 2 0 Expiration Date: <br />Date: i I b I p —1 '�Contractor: t'`'n V . CO v�7`r L Ac --;-cc 1 _. <br />Signature: - - �.- J+G <br />Title: 5 <br />PriMed name: l dot_ �H <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />—1 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 />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. __- ST•q �c,>Policy Number. 1'> <br />4-l–12–ZUc <br />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: to/ f t? `7 Signature: _ \ <br />Printed Name: <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 714OUSAND DOLLARS <br />($ID0,DM),,IN ADDITION TO THE COST,OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED' FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize (print <br />vb J` e�,Fre <br />ofC-57 licensed authorized representative), <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 application. <br />8-29-021 MI <br />EIlD 29-02-001 <br />6/22/04 <br />