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FROM :ResgnantSenicInternational FAX NO. :5306682429 Dec. 23 2004 01:56PM P2 <br /> DEC 23 2004 13:27 FR OH TECH 4092322801 TO &6Ee2429 P.03/03 <br /> San Joaquin County Environmental Heelth Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR*., Dv7D <br /> ��-rcy%,CA ooqL& <br /> LICENSED CONTRACTORS DECLARATION (LCQ) <br /> 00 .3 <br /> I hereby affirm that I ern licensed under the provisions of Chapter 8 (commencing with Section 7000)of Division <br /> 3 of the Business And Professions Code and my license is in full force and effect. <br /> 12,b ILO <br /> License*: Explraation Date: (a s'" <br /> Data: za Contractor; �-- <br /> Signature: TiN11: <br /> Printed name: _ <br /> VO/04- 118' COMPENSATION DECLARATION <br /> I hereby affirm under penalty'of parjury one of the follow)ng 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 /> e'�--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 /> career and policy numbers are: <br /> Carrier: Policy Number: /6 6 E' <br /> I certlry that in the performance of the work for which this permit Is lasued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensallon laws of Callfornla, 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 thos revisions. <br /> Expiration Data: P-"/X- Signature: <br /> Z1/10(' Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALT-SUBJECT <br /> AN!EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 of THE LABOR CODE. <br /> AUTHORIZATION FOR 0TH THAN C-57 SIGNING PERMIT APPLICATION <br /> / (eignature ofC-57 licensed authorized representative), <br /> herabyautherize(print naa�o) L-,, t 7(,, •A'�a<�' <br /> to sign this Saran Joaquin County Well Permit Application on my behalf. I understand this authorization In valid for <br /> one(1)year and is limited to the work plan dated on the front page of thio application, <br /> B-29-021 MI <br /> viae yo.m-not <br /> ** TOTAL PAGE.03 ,k* <br /> DEC 23 2004 14: 19 5306682429 PAGE.02 <br />