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"1,92/22/2005 10:43 91686164x9 SECOR PAGE 02/02 <br />6J <br />Saar Joaquin Catrnty Environmental Health Department Unit IV Welf Permit Application Sup I men <br />JQB ADDRESS, �1 an i c., _�, c �4h 91.,,3 _ PERMIT SR#,,—. r) ql(,1 -7 (a • <br />LICENSED CONTRACTORS DECLARATION (LO) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 tcommencing with section 7(100) of Division <br />3 of the Business and Profess <br />siions Code and my license is in full force and effect. <br />� <br />5� <br />License #: Ct % IO :7 Expiration Date: ____(. _ /= / /0 <br />Date: Contractor: r'r�!/,r'� 'Y.(7�1f� <br />Signature TitIe;("Y1 71..10;` _r <br />Printed name;� <br />JIF <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 certifloete 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 thls 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 far which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are, <br />Carrier: Policy Number: 4t6 /0 `f' 0 ?'6 <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 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: ignature: <br />rinted Name: ��',t � rte- /O e � _ __ <br />04 OK- <br />WARNING: FAILURIE 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 DAMAOEe AS <br />PRCOVIDED FOR IN SECTION 31'06 OF TKE LABOR CODE. <br />ALITHORI?_ATION FOP, OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, - (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name)j0.r•+�-br D �.- , Dt- !a 6 e O?,. <br />to Sign this San Joaquin County Well Permit Application an my behalf_ 1 understand this authvrigalion la valid for <br />one (1) year and Is limited to the work pian dated on the front page of this application. <br />E• Ha 24.02.Ml <br />6/22/04 <br />Z© 39Vd DNI-TII�IG 993N9 ZKOCITESZ6 25:01; Booz/z1,;/Z© <br />