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FROM :ResonantSonicInternaticnal FAX NO. :5306682429 Dec. 27 2004 10:12AM P2 <br /> DEC 27 2004 10:24 FR TECH 4082322801 TO 9,6682429 P.02i02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRE38: 19t% $ L9 S6 Y1( D hL_ PERMIT SR#: ®D Do C <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divlelon <br /> 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License#: ga a- 3 3,/ Expiration Date: �- a <br /> Date: 1 Contractor. <br /> Signature; <br /> Printed nemi, / <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certificate of consent to self-insure far 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 /> , Lct 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 f4-.�(..- Policy Number: 1G61'& r/o / <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' cnmpensatlon provisions of Section 370D of the Labor Code, I shat <br /> forthwith comply with those provisions. <br /> Expiration Date: rZ -) - Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATIO(CCOVIRAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN BEC11ON 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> I, 4- (signature ofC-57 licensed authorized representetive)r <br /> here authorize(grin ame) .—rte /,� /Z' _ <br /> to sign this Ban Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(f)year and In linitsd to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EHD 29.02.001 <br /> N))IOa <br /> ** TOTAL PAGE.02 ** <br /> DEC 27 2004 10:35 5306682429 PAGE.02 <br />