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FROM :ResonantScnicInternational FAX NO. :5306682429 Nov. 07 2005 02:36PM P2 <br /> NOV 07 2005 13:05 FR H TECH 4082322801 TO.306682429 P.02iO3 <br /> San Joaquin County�Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDR555: leA. Ave ) PERMIT SRW: <br /> LICENSED CONTRACTORS DECLARATION (LCQ) <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 /> License Is: e 3 3 f Expiration Date: <br /> Date: Contractor <br /> Signature! Title: <br /> Printed ams: 4. <br /> V06RKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a nertNloata 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 /> Carrier S-(n4� ?'u_-.,. Polity 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 Ssetlon 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: / ' Signature —_ <br /> Printed Name: %1 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION G ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1 00,000J, IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES A9 <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> QUTHORIZ� TION7� Z <br /> ROTHE(�THAN C-67 SIGNING PERMIT APPLICATION <br /> I - \ ��v _ (signature ofC-57licensed authorized representative), <br /> hereby authorize(print na ) lgy1 LD'_6m1r <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Ic Ilmited to the work plan dated on are front page of this appfleatlon. <br /> 8-29.021 MI <br /> FWD 29-02-M1 <br /> An INW <br /> NOV 07 2225 14:57 5306682429 PRGE.02 <br />