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12/07/2004 09:54 9168610433 SECCP •/ PAGE 04/04 <br /> mA v/1n ,Zf 21'67' <br /> V �"` � ) <br /> San Joaquin County Environmental Health Department Unit N Well Permit Application Supplement <br /> 1 <br /> JOB ADDRESS: {(o`l� C � P�� Cc_ - �(1 •(A PERMIT SRIF: <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#: 71 OO� 21 C--S" Expiration Date; 31 05 <br /> Date. - -7- Contractor +` A h� ��]dX 1 11 ✓1� 4(� <br /> Signature: 7�Gc��-+a L� (�!/Vr-��J���'e- Title: gt,C <br /> Printed name: <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 /> �.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 /> tamer and policy numbers are: ,.I <br /> Carrier: �S-� ifc ru '�f J Policy Number: <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 iaws of California, and agree that if 1 <br /> should became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: <br /> /0110 S Signature: <br /> Printed Name: ! nJc i �/ 6 L— (tiDda ✓R <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 TEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION <br /> �FOR <br /> � OT�HER�THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, L-M!_-r'(J L - C—�.�—/-—syr��J"`r'"'—+•�� (signature ofC-57 licensed euthod:ed representative), <br /> hereby euthorl=e(print name) 1-4, ' "`o � <br /> l to sign this San Joaquin County Well Permit Application on my beh2H. I understand this authortzatfon Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> II/MI <br /> eHD 2"2401 <br /> 5/22/04 <br /> rou[j auTTTTia paumpoom 00£bf L£LOL XVd ZT:TT 600Z/L0/9T <br />