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09/12/2007 10:05 2093345j74 <br />WGR SOUTHWEST NOCAL <br />e <br />lvv�t le <br />PAGE 03/03 <br />San Joaquin County Environmental Health Department Unit IV well Permit Application Supplement <br />JOB ADDRESS: Reld Drive at Luce Avenue PERMIT SR#: ®�2n <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 #: 6a 33 Lf Expiration Date: <br />rT <br />Date' <br />Signa <br />Printe <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 />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: /7 <br />Carrier: Policy Number: 77/ 3 — 1553 -7 —d <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 H I <br />should become subject to the workers' compensatio ions of Sectio of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: 1 Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA'&E 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 A5 <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />hereby authorize (print <br />TION FO THER THAN C-57 SIGNING PERMIT APPLICATION <br />.tie <br />ofCv7 licensed authorized representative), <br />to sign this San Joaquin Count/ Well Permit Applicatfon 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 appll"bon. <br />EHD 29.02-0pr <br />6/22/Na <br />