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0713 W� <br /> Application Supplement <br /> San Joaquin County Environmental Health Department Unit IV Well Permit App 01154��� <br /> JOB ADDRESS: "01South center Street, Stockton PERMIT SR#: <br /> p57- Z? W. S<D Z7 �. <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 /> 680227 Expiration Date: 30 November 2011 <br /> License#: <br /> Advanced GeoEnvironmental <br /> Date: 12-26-2009 Contractor <br /> 1^/��', Title: Geologist <br /> Signature L&1�JLt�i�� <br /> Printed name: William Little <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 /> carrier and policy numbers are: <br /> Travelers Casualty Insurance Cc UB333BT982 <br /> Carrier: Of America 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 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 /> 17 October 2010 <br /> Expiration Date: Signature: t � <br /> William Little <br /> Printed Name: <br /> COVERAGEWARNING: FAILURE TO SECURE WORKERS' COMPENSATION SUBJECT <br /> AN EMPLOYER O CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED($100,000.), IN ADDITION TO THE FOR THE COMP SATION ,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> FOR N SECTION 3706 <br /> AUTHORIZATION FOR O HE THAN C-57 SIGNING PERMIT APPLICATION <br /> INV (signature ofC-57 licensed authorized representative), <br /> i <br /> hereby authorize(print name) <br /> to sign this San Joaquin County ell 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 /> 8-29-021 MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />