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'• - - ,,,,,,� 5305892230 TO:12099460621 <br /> P.2 <br /> San Joaquin County Environmental ealth Deparimen Unft IV Well Permit Applicati7,supplemL",nt <br /> JOB ADDRESS: 3 6 AbA, e- f PERMrr SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> hereby affirm that 1 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 elle _ <br /> License#L �-+4 O LSI �r <br /> Expiration Date: <br /> Date: Con actor [2r)Fj <br /> Si®nature: Title: f�(1itC/i <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$ection 3700 Of the Labor Code,for the performance of the work for which this permit is issued. <br /> X1 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 /> CarrlerUUn 08 Al PolicyNumber. Q6OI3�-3b ACID <br /> 1 certify that In the performance of the work for which this permR Is Issued, I shall not tmlpkry any person In <br /> any manner so as to become subject to the workers' Com ensation laws of California, and agree that if I <br /> should become subject to the coo kers' compensation sions of Section 3700 of the Labor Coda, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: / / Q Signature: <br /> Printed Name: �!/GAIL �flLGl� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SNALL 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 CODC. <br /> / AUTHORIZATTION FOR 0TNER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signzdure ofC-67 licensed authorized mpresentative), <br /> hereby authotlze(print name)_ <br /> to sign this San Joaquin County Well Pernit pplloation on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is nmltod to the work plan dated on the hunt page of this application. <br /> B-29-02 1 MI <br /> 002D.02-001 <br /> 9/10/2002 <br /> 05/17/2004 MON 14:49 [T%/R% NO 53741 16002 <br />