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AVII@ I A G <br />San Joaquin County Environmental Health Department Unit 1V We)l Permit Application Supplement <br />JOB ADDRESS:'3c3� E_ i?-ck PERMIT SR#° <br />LICENSED CONTRACTORS DECLARATIONL( CD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of Use Business and Professions Cade and my license is in full force and e*q.. / <br />License c Expiration Date: (I 3 <br />J, <br />Date: Lri AS ContracWr: /r l , f C <br />Signature: /fir Title:- fr07, <br />� PrinteQ Warne: dWa!' ,1 <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 Coda, for the performance of the worts 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: / �9 hVId J Policy Number: MS— X00 <br />I certify that in the performance of the work r 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 became subject to the workers' compensation provisions of Section 3700 of the labor Code. I shall <br />forthwith comply with those provisions, <br />Expiration Date: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIOMNAL PENALTIES AND CAVIL FINES UP TO ONE HUN13RE0 THOUSAND DOLLARS <br />(;100,000.1 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEYS FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR COOS. <br />AUTHORIZATION FOR (?TREK THAN C-57 SIGNING PERMIT APPLICATION <br />I, E441('(signature ofC-67 licensed authorized representative), <br />r <br />hereby authorize(print name) LVIACJIIQ_ rl��ej7 Wr 4 dtl4nCed ^ nUifC�lv►�Qa17S:l <br />to Sign this San JrAgtdh CGunt 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 that application. <br />8-29-02 f MI <br />ERD 14-0:3.001 <br />6122/04 <br />