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05/16'2005 WED 10:02 FAX Q002 <br /> _`t: i�, • pnt]E hl'-'/LTi <br /> 19/21J2MJ3 L92: =y ti16H4�104J� . <br /> San Joaquin County Environrnuntal H�ea�K6 Diepartment unit IV Well Pennft Application Supplement <br /> JQB ADDRESS:!-IaLbA . tom^ PERMIT SR#: <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 f3usin�e7ss and Pfofessi ns Code rind my license is in full force and ffect. L �� <br /> Licrnse o:—1 O C� _'Exp' tion Date' IIA .— <br /> Date:_ Contra tor:_ <br /> T ttte: <br /> Signature: �\y-1n ��I.! ��i ` <br /> Printed name: lN-Al <br /> WORKERS' COMPENSATI 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 Sectio, 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 performanee of the work for which this permit is issuPd. My workers'cOmpansation insurance <br /> carrier an policy numbe are- <br /> Policy Number: <br /> 11 <br /> Carrier: G r `/ <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' compensa 'on provisions of 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: _-- <br /> Signature: e1 <br /> l LCL <br /> Printed Name: DCOVEGr-is_. <br /> +A101$HALL, <br /> AW ARNING: FAILURE TO SECURE N EMPLOYER O CRIMINAL PENALTIES AND C VIP .- NESTON UP TO ONCE HUNDRED THOUSAND OLLARSUBJF:CT <br /> ($100 000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> jA,UT, HO 117JwION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ✓t�il�/i .Cl �'1 (signatures ofC-57 ticensud authorizad representative), <br /> hereby authorize(print namq)�_ _` V <br /> LU.2 <br /> signthisSan Joaquin county Wall Permit APPllcatlon yin my benalf- I underRland thisaulhorl7Rtlen is valid for <br /> e(f)yearandIr.limited to thn workplan dated on the front P:'CP of thia application. <br /> 9-02 1 M! ...._.. —.— �.. <br /> T4 11 :\O ;f•/„ � rIOgP <br /> 05/18/2005 WED 11: 17 [TX/RX NO 57631 002 <br />