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FROM :ResonantSoniclnternatr.onaFAX N0. :$306682429 1� 16 2004 11:06RM P2 <br /> Dec 13 04 03: 09p <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 7 PERMIT SR#: 46 O to / <br /> Tey -CA <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I em licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions C009 and my license is in full force and effect. <br /> License# �e'i_3 3 y Expiration Date 12 a y- <br /> Date �z1o•7 Contractor. e-..- a- L <br /> Signature; Title; <br /> Printed name: T—� ry •, ._ <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 /> y� I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work tot which this permit is issued. My workerscompensation insurance <br /> Carrier and policy numbers are' <br /> Carrier:• Policy Number. <br /> 1 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'COMpensaliun 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: f nT Signature: — r <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION OVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (51(110,000.),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-57 SIGNING PERMIT APPLICATION <br /> 1, � ---- (signature o(C-57 licensed authorized representative), <br /> hereby�a horize({yt t p ne) !� /t 5 �P_M�a C <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 appllcaGon. <br /> 829-021 MI <br /> END z9 uz vni <br />