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ilad1511 <br />AA,te.15. <br />/tadeff4 -Of/ co-31 <br />aquin County Environmental Health Depa <br />JOB AD RESS: 100 St- aw -Rcoa <br />ciK 54ate-- /2-ae <br />ent Unit IV Well Permit Application Supplement <br />PERMIT SR#• °51/511 <br />.05-ff <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 and effect. <br />License #: C S -111 '51 0 Expiration Date: k / 31 /10 <br />Date: 0S- Contractor: C>•-.V.ACQ€_ ‘Ni) <br />Signature: Title: tDS . M.Vr • <br />Printed name: Pzkv,..t "NieU.15Y-10 <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 />2c1 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: li\sa-S 1/10-410%A-0,1 Policy Number: 'nE IN'S SO 6 3 <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: 5-- t 0 Signature: <br /> <br />Printed Name: SV\9--k.S <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 3706 OF THE LABOR CODE. <br />AUTH IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-87 licensed authorized representative), <br />hereby authorize (print name) V / 61-7r Mue /-2/6-e4 <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 />8-29-02 / MI <br />EliD 29-02-001 <br />6/22/04