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t ' :r <br />06/30/2004 09:05 9168610430 SECOR <br />K <br />San .Joaquin County En-, <br />PAGE 03/03 <br />_/l �(� 6ii-� <br />Health Department Unit IV wall. Permit Appiioatloni�o Suupplem€�nt <br />JOB ADDRESS ��/ �+ �+oo,- AOr PERMIT SR#' ��� <br />o <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Secticr, 7000) of Division <br />3 of the Business and Professions Code and my license is In fuil force and effect - <br />License #: Expiration Date: <br />Contractor <br />Signature: L' A o --- <br />Printed name; <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CH2CK ONE) <br />_ I have erd Ml', maintain a certificate of consent to self insure for workers' compsn3atioi 2s provided for <br />by Section 37CO 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 workars' compensation trsurance <br />carrier and policy numbers are: <br />Carrier;. r7�f1✓� Policy Number:��J�G>�2�2 sP <br />1 certify fnat Ir the performance of the work for which this permit Is I331ed, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation, laws of Caiifomia, and agree that if I <br />should become subject to the workers' compensatlon provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those pravislons. l _ I A <br />Expiration Data: - l -�- �"t 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 PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000,), IN ADDITION TO THfi COST OF COMPENSATION, INTEREST, ATTORNI_Y'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 />n� (signature ofC-67 licensed authorized representative), <br />hereby authorize (print name) C �iiyT _S <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 appucatlon. <br />-29-02 / MI <br />EHD 29.02.001 <br />9/30/2003 <br />Z00In <br />sUTTTTaQ P-11?%kp00i1 <br />00.'ttLE10L Tl':l 9E:60 EOOZ/6Z/60 <br />