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12/97/2094 99:54 9168610430 <br />pi-mibt{ <br />SECOR <br />lc-7 /6 Y70 a1A-lk:lec ) <br />San Joaquin County Environmental Health Department Ur* IV Wall Permit Application Supplement <br />JOB ADDRESS: 1(02wo cf CA1-1,rt,9 _c 4- PERMIT SR#4, VO <br /> <br />1,22 — O Z"/ Contractor. __CAJOLEXASaainthid_ta_—S C. <br /> <br />Signature: : , <br /> Printed name: C--.0 4.1 ..61.) .4. 6-7 I-4)669 D w2 -4, - <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 Code, for the performance of the work for which this permit Is Issued. <br />k. 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: $tia -Fai YID Policy Number: Z( <br />I certify that In the performance of the work for which this permit Is issued, l 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: / 46/6.5- Signature: <br />Printed Namc C-C) t#"JL)OIJID <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 OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 37C5 OF THE LABOR COVE. <br />AUTHORIZATION FOR orthER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br />hereby authorize (print name) <br />to sign this Sall 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 />EI-29-02 / MI <br />EHo29-o2-aot <br />6t22/04 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that! am lioensed under the provisions of Chapter 9 (cx)mmencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license Is in full force and effect. <br />License #: —7 1 00 q c-s Expiration Date: L31— <br />Date: <br />i:00 SUITIIJU pJampOOm 00£ftLUAL YVA TT:TT tOOZ/LO/ZT <br />PAGE 02/04