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t <br />12/07/2004 09:54 91E9610430 <br />//7-//0 <br />,z <br />San JosquIn County Enviroranentil Health Departa-nent Unit. Well Pc7mIt Applicatlon i'itupplement <br />---cv <br />JOB ADDRESS: at- I-SAC Or PERMIT SR#: 400 t () <br />LICENSED CONTRACTORS DECLARATION (LCQ) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />i: of the Business and Professions Code and my license Is in full force and effect. <br />License #: ___C.„-_,...5-1-7 Expiration Date: 7:131: C)5 <br />Date: a - '2 - CA-I Contractor. Cz.)CISA2...0 r.---)Z, 11 t [P. CO <br />--...)--z—T I tie : <br />Printed name: _C_Cl/J 1/1-),0 (-<.) <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 certtficate of consent to self-insure for Workers compensation, EIS provided for <br />by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />X_ 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: 64- A4 E. ___ Policy Number: 4-4 <br />I certify that In the performance of the work for which this permit is issued, I shall rot employ arty person 1r <br />any manner so as to become subject to the wor'kers' compensation laws of California, and agree trat 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 Data: / O /74' SIgnatune: <br />Printed Name: (1,0 I/0 04).QU) a- <br />WARNINQ; FAILURE TO SECURE 1NORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CD.% FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COtilEENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OP THAN C-57 SIGNING PERMIT APPLICATION <br />(-430-0"----•e--.,--c7z----4 (signature ofC-G7 [lensed authorized representative), <br />hereby authorize (print name) 1?).,_ +I <br />to sign this San Joaquin County well Permit Application on my behalf. I understand thls authorization Is valid for <br />one (1) year and Is limited to the work plan dated on tho front page of this application, <br />8-29-02 f MI <br />E151) 29.0-001 <br />6/22/04 <br />Signature: <br />SECOR PAGE 03/04 <br />o ETTT-la ImmtpoOli 0043-t1U.02. XVA 1I:IT t.00g/L0RT