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(signature ofC-57 licensed authorized repreSerttative), <br />hereby authorlre (print name) <br />hey\ <br />4/ aa.,‘ 1,447 GEOLOOP DRILLING 4 12094683433 NO 026 <br />aiu.. i uutu sECOR-SACRAMENTo • <br />t <br /> <br />`e-6-X)+0 11-t:T—JrIC LAW' V‘-& <br />CIOR) 14 L°C1) 514 <br />JCY6 ACIDRESS: W/C). kA)0k6i.t) "c24 PERMIT SR#: (9/9 <br />'''OCA6.4117.) CAZ1 <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 #: 3T 2-L Expiration Date: <br />Date: <br /> <br />Signatur Title: <br />Printed name. -e tt- 2 ook <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self .insure for workers compensation, as provided tor by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, <br />.K 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: INte(iie p fit/ ti6 Policy Number: 14) EY O 0 0 I q0 I <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 previsions. <br />Date: /-/-- 6) a <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUSJEcT <br />AN EMPLOYER TO CFIIMINAL PENALTIES AND CIVIL FINES UP TO ONE NuNDRED rHoUSAND DOLLARS <br />(V 00,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br />Eign 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 %fated on the front page of this application. <br />5-17-2000 / Mt <br />Joaquin County Esylennmental Health ServiCeo, Unit IV Well Permit Application Supplement <br />?t) <br /> <br />Contractor: vi4a ,7k. <br /> <br />Signature .