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wjVVG/VV,? <br /> FREPI Gru"n& ;crj Ari,- 1 List s � � PHONE No, : 209 835, 98rJ3 13 2012-K ©9:18PP1 P3 <br /> Sari Joaquin County EnvirQntnental Health laepartmarif Unit IV Well Permit Application Supplerriont � <br /> JOB ADDRESS: 6461 Almo-rijwood Drive, anted CA PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCO) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (ccmmencing with Section 7000) of Division <br /> 3 of the. Bustness and Professions Code and my license is in fall forwand effect. <br /> License k C�7-720904.. Expiration Date: <br /> nam' ` Conti c#or, _. V&W Drilling ln% <br /> Sionature: f� Title: <br /> Printed name! <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby Offirrri tender penalty of penury one of the following declarations: (CHECK ALL THAT APPLY) i <br /> I have and will maintain a-eertlflrata of eansent to self-Insure for workers'compensation; as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which thio perrnit is•issued. <br /> I have and will maintain workein' ournperlsation insLMnoe,as required by Section 3700 of t,`le Labor Codd, <br /> for the porformanco of the work for which this permit is Issued. My workers'compensations insurance <br /> carrier and Policy numbers are:: <br /> "Carrier. fkAl 7.1r l Policy Number: � <br /> _I certify that In tl ie 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 cf California, and agree that if I <br /> should become subject to the workers' compensation provisions of Sectlon 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> f <br /> data: .� �L��L..� Signature: � /e" <br /> Printed Name: �' ks <br /> Ir <br /> WARNfuO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1S UNLAWFUL,AND sl IALL 6(1BJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,004,),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PRONIII) ID FOR IN SECTION a766 OF THE LABOR CODE. <br /> I, [�U�' ✓� (signature afC-57lltensed autharized rapresentative). , <br /> hereby authorise(prim n$ms) JZLane of Ground Zero Anallsia <br /> to sign this San Joaquin County Well Permit Application on my behalf: l understand this authorizatlon is valid for <br /> One(1)year and is lirnibed to the work plan dyted an tho front page of this application. <br /> i 1-25-021MI <br /> 06/13/3008 TUE 07:4$ (T-X1R.Y NO 71351 2003 <br />