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PAGE b� <br /> 10/27/2003 11:12 20946834 <br /> FIFTH FLOOR • <br /> San Joaquin County <br /> Environmental Health Department Unit fV Well Permit Application Supplement <br /> I� <br /> ab �dPERMIT <br /> SR#: <br /> � � 1 <br /> JOB ApbRESS: �,rac.y� �' <br /> CTORS DECLARATION �) <br /> LICENSED CONTRA of Division <br /> rovisions of Chapter 9(commencing <br /> with Section 7000) <br /> I hereby affirm that I d professions licensed under the P license is in full force an�e /� / <br /> 3 of the Busin/e�ss`S / /00 nd y Expiration Date: S <br /> License <br /> / t4 j, 'q Contractor: ` e� <br /> Date: Title:Lo <br /> signature: 7 <br /> LJ , <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> T APPLY) <br /> hereby affirm under Penalty of perjury one of the following declarations (CHECK ALL a on as provided for by <br /> performance of the work for which this Permit's Issued. <br /> I <br /> have and will maintain a certificate of consent toself-insure for workers'come <br /> _ -Section 3700 of the Labor Code,for the p as required by Section 3700 of the Labor Code, <br /> sation insurance, workers'compensation insurance <br /> have and will maintain workers' comp <br /> en <br /> for the performance <br /> ofor Permit is issued. MY o L <br /> carrier and p Y numbers wrk Policy Number: <br /> Z.} �L 1 O an person in <br /> Carrier: '� <br /> _1 certify that in the p I compensation laws of California,and agrees I ishall <br /> Pe of the work for which this permit is issued, I shalt notanemploy <br /> provisions of Section 3700 of the Labor Code, <br /> any manner so as to become subject to the workers' <br /> should become subject to the <br /> roworkons_compensation <br /> forthwith comply with those p <br /> 1� _Signature. / <br /> pate: Gv/Y> <br /> Printed Name: WFUL,AND SHALL SUBJECT <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLA <br /> AN RNING: FAILURE <br /> TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNpRED THOUSAND DOLLARS <br /> ($100,00ED,ORIN DIN SECTION 3706 OF THE L=COST OF ABOR COMPCODEENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> DITION TO THE <br /> PROVID <br /> � � (signature ofC•571icensed authorized representative). <br /> \�tet\,\ \1 J\ C1\x LIQ 1� _ <br /> hereby authorize (print name) <br /> D . <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> .no(1)year and is limited to the work pian dated on the front page of this Application. <br /> 1-25.021 MI <br />