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FROM ,Resor.antSonicInternatienal FRk' N0. :5306682429 Dec. 23 2004 01:57PM F3 <br /> DEC 23 2004 13:26 FR WH TECH ' 4082322801 TO 006682429 P.02/03 <br /> San Joaquin County_Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: -roe &= 4Z Peu1.jX PERMIT SR#: <br /> t8`%4 12;sb flew wow <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter B (commencin®with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: o 'z. -3 .�y Expiration Date: T i/a <br /> Date: contractor. <br /> Signature: r� f� «— Title: <i <br /> Printed name: I <br /> WORKERS' COMPENSATION 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 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: S4 .+- Policy Number; v Sc s- <br /> r i <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 Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. A/ <br /> E=xpiration Dat®, I o Signature <br /> Printed Name: 41.-:_ - - <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IB UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS i <br /> (1100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. i <br /> AUTHORIZATION FOR OTF/ER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-e7 licensed authorized representative), <br /> her y authorize(pf nt name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(f)year and is limited to the work plan dated on the front page of this application. <br /> 9-29-021 MI <br /> Fun 7,9.07.001 <br /> DEC 23 2004 14:20 5306682429 PAGE.03 <br />