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09/20/2005 12: 92 5105687679 VIRONEX PAGE 01 <br /> 08/20%'2005 13:27 FAX 916 362 5 KENNEDY JENKS • Z002 <br /> San Joaquin County Environmental Heal h Department Unit IV Well Permit Application Supplement <br /> JOB ADQRE5SS: , ������ a' PERMIT SR#: <br /> � �-� M I <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing wlth Section 7 000)of Division <br /> 3 of the Business and Proressions Code and my license Is in full force and effect. <br /> License ��S�o�� 3� ' 0-7 <br /> Expiration Date:. _ <br /> Date: <br /> OCa S Contractor. V I r Doe <br /> Signature: Title: eQ�1Ck'tr <br /> Printed name: C, �2�}'1Gtr1'fl <br /> WORKERS' COMPENSATION DECLARATION <br /> I herelzy affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will mointain a certifcate of consent to asif-insure for workers'compensation, gis provided for f <br /> by Section 3700 of thu 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 D-the work for which this permit Is issued, My workers'compensation insurance <br /> carrler and <br /> policy numbers are: <br /> Carrier: Policy Number, G3C- LS 1 'S-3 O 7. <br /> I r-ertify that in tht,perormanee 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 Calffornia, 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 chose provisions. <br /> Expiration Date: Imo• IS•©Cfl Signature: +� <br /> Printed Name <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN GMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (s9O0,OOD.), 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 0TWER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (slgnatum ofC-57 licensed authorized representative), <br /> hereby authorize(print name) n to Al , <br /> to 91gn this San Joaquln County Well PQlmit Application on my behalf, I understand this aL411oriaatlon Is valid for <br /> I <br /> one(1)year and Is limited to the work plan dated on the front page of this applicatson• <br /> e-29-02/MI <br /> EHD 29-Da•001 <br /> Grza�a� <br />