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v' <br />31--4�..27. 2005 12' 19PM f1PE;; ENVIROTECH, INC. NO. 417 P.2 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supi ment <br />JOB ADDRESS: �4��, an . PERMIT SR#: � <br />LICENSED CONTRACTORS DECLARATION ,LCD) <br />I heroby 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 foreo aeffect. <br />ef-'ect. <br />License *:: 7 M-1 1 Expiration Date: r V-7 <br />7 <br />Date: I I., 16 5 Contractor. ryl, <br />Signature <br />VY-e, <br />Printed name: 1 r I <br />WORKERS' COMPENSATION DECLARATION <br />I 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 />✓1 ehavo 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' comoensatlor) insurance <br />carrier and policy numbers (� <br />Carrier: �.ble - Policy Number' Z A O— 93%- <br />1 <br />3O-1 certify that in the performance of the work for which thle permit Is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation lows 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 pmvlslons. <br />IIA <br />Expiration Data: 1� �; �5 Signature: • <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUDJECT <br />AN EMPLOYER TO CRIMINAL, PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOyU,SAND DOLLARS <br />($100,000.), IN ADDITION TO THE C0gT OF COMPENSATION, INTEREST, ATTORNEY'S Or -ES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE, <br />AUTHORIZATION FOR OTHE THAN C-57 SIGNING PF-RMIT APPLICATION <br />1,Ctn rli e, W oLt0 & rd (slgnatum ofC•5Lficensedlauthorized represontative), <br />hereby authcrixo (print name <br />K -- <br />to scign this San Jomquin GountyWell Portrait Application on my behalf. I understand this authorization is valid for <br />oM6 (1) year and is Ilmhtd to the work plan dated on the front page of this application. <br />9-29.021 MI <br />EM 29-02.001, <br />6/22/04 <br />