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4 <br />rIrcL1tI GeNFLUFN.MIILAI <br />iiVI1 %.1 <br />tan Joaquin County Environmental Health Department Unit IV Well Permit Appl atlo ppiement 6 <br />JOB ADDRESS: a20 1 5 Olovizi cAuF02441/4, Si. PERMIT SRO: 117' <br />Sr0C-14-1-0 NI <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am named under the provisions of Chapter 9 (commencing with Section 7000) of DMsion <br />3 oi the Business and Professions Code and my license is In full force and effect. <br />Liconse it: 5 Expiration Date: 0 4 - 3 0 - 0 7 <br />Date: WO5 Contract . Spectr, EXicloration. Enc , <br />Signature: TRW Regional Manager <br />Prilted name: <br />WORKERS' COMPENSATION DECLARATION <br />I horeby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I nein!, and will maintain a certificate of consent to ..If-Ineure 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: National Union Fire <br />permit Is issued, I shall not employ any person In <br />riots' corn nsation laws of California, and agree that If I <br />sation provi one of Sect' n 3700 of the Labor Code, I shall <br />Ex Diration Date: 0 4 -1 0 - 0 7 Signature: <br />Printed Name: <br /> <br />ekriflaAr <br /> <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CM. FINIS UP TO ONE HUNDRED THOUSAND DOLLARS <br />($1 00,000.), IN ADDMON TO THE COST OF COMPENSATION, INTSNOST, ATTORNEY'S PREIS, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN 047 SIGNING PERMIT APPLICATION <br />I. :i m glah 4 r f1 clap/ Rp.pc_t- ruff! ;Iv rl 1.114* itipiture ofC47 licensed authorized representative), <br />hereby authorize (print name) M KE: ,VL-15(C-1-1 FOC/T14.11.10 et.-16.1 PFEIL! I..) 6. <br />to Agin this San Joaquin County Well Permit Application on my Oohed. I understand this authorization Is valid for <br />onl (1) year and Is limited to the work pion dated on tits front pap of this application. <br />/ MI <br />Etil):9-024101 <br />60.2104 <br />ins aflc CQuiafly <br />I certify that in the performance of the work <br />any manner so as to become subject to th <br />should become subject to the workers' co <br />forthwith comply with those provisions. <br />Policy Number: 1 1 7 7 8 6 0 <br />11/1613/21310b id:07 ,02741DOUt(3