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111 <br />rd. <br />I C.) <br />12/07/2004 09:54 916861043e <br />6ip /42 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: )(097-0 C) PERIVIIT SR#: <br />LICENSF_D CONTRACTORS DECLARATION (OP) <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 # 71 00 q 5-1-7 Expiration Date: 7-7 <br />Date: J(9- 0 44 Contractor. ( A )(1)( r"-)eil CO. <br />si gnature: il TItle: <br />Printed name: C-0 6:7 <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 />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: c.S41=4 d Policy NUM bar: 014 1-kr1gni-22) <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 provisions. <br />Expiration Date: /4 Signature: <br />Printed Name: <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 />(6100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature fC-57 licensed authorized representative), <br />hereby authorize (print name) /14c- If Le Lo <br />to sign this San Joaquin County Well Permit Application on my bshalf. 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 />849-02 I MI <br />END 29-02-001 <br />5/12/64. <br />1700 En 2uTITTJa paempoom 004:ftLU.01 XVA gi:IT <br />AJC /1/4/ 6--7- 1,1friC- <br />SECOR PAGE 04/04