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! <br />0S/30/2004 09: 05 91E8610430 SECOR PARE 03/3 <br />iir-O 4,4 -‘;1A-,•• <br />San Joaquin County Environmental Health Department Unit IV Wo Permit Application Supplement <br />JOB ADDRESS:t4-Y or ht),./.2) 44fer- ovt' Por' PERMIT SR#: §),4 z <br />eve ret 49def) oiovf ap-41.-- <br />Ct) / zo 3g1-21 <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 end effect. <br />License #: <br /> Expiration Date: <br />4-/ <br />Contractor: jr,4".40 A-/, <br />Signature: <br /> <br />Printed name: <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 salf-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: <br />Carrier: Policy Number: 4:7W e'ia:2,70'Z.V.? <br />I certify that In the performance Of the work for which this permit is ISSLied, I shall not employ any person In <br />any manner so as to become SubliOt 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 shell <br />forthwith comply with those provisions. <br />Expiration Date: /C at/ Signature: <br />Printed Name: ‘4/1-14(<5 <br />WARNING: FAILURE 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 OP COMPENSATION, INTEREST, ArroRNEY'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 />---,d itdri-24c7 (signature ofC-57 licensed authorized reproaeritative), <br />hereby authorize (print name) ..."4-44/7 --- /1/174-44-5 f‘ <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 application. <br />E1,29-02 / PtI <br />EHD 2941-001 <br />9/3012003 <br />?/.777,e17_5— <br />Date: <br />2uriTTJa pJeApoom 00£ttLEL0L XVA 9£:60 £00Z/6Z/60 ZOO 2