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APR -26-2004 14:39 FRON:ENPROB 5375992230 TO:12099490621 P.2 <br />V 1I LV/ENVY J.JLY /'f1A LVJ �YVVULI <br /><<r,-) . <br />24- -S o <br />_-r- D -4to J A <br />San Joaquin County Environmental He Ith De artmsnt Unit IV Well Permit Application Supplement <br />JOB ADDRESS:I'v C' YY <br />�C �� Up�' PERMIT SR#: v <br />yr 6F S�v,V4or\ <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that t 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 effe <br />License # Expiration Date: <br />Date: ontractor: p �0 <br />Signature: Title: l�.i�/✓�i /li <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />t 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 />I 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: -I mbUAV Policy Number:J��-����� <br />1 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' compensatio rovisions of Section 3700 of the Labor Code, I shall <br />forthwith com with t se provisions_ <br />Date: Signature• <br />Printed Name: Jr--�9,v Q �Q <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 THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN 5ECTION 3706 OF THE LABOR CODE. <br />AIJT14' fRIZAJTION,FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Y <br />A (slanature ofC•57 licensed authorized reprEsentative), <br />hereby authorize (print name) - <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 />B-29-021 Mi <br />04/26/2004 BION 15:39 [TX/RX NO 99491 U002 <br />