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FROM :ResnnantSenicInternational FAX NO. :5306682429 . 23 2004 01:56PM P2 <br /> DEC 23 2004 13:27 FR *H TECH 40l�2322801 TO ec6682429 P_03/03 <br /> San Joaquin County Environmental Heelth Department Unit IV Well Permit Applicatiioo/nn Supplement <br /> JOB ADDRESS: PERMIT SR*., &Ab g�� <br /> -WY%t to DD 3 fo <br /> 3 <br /> LICENSED CONTRACTORS DECLARATION 11 CQ� s <br /> I hereby affirm that l 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. 2- 10 <br /> /J. <br /> - <br /> License#: .zy Expiration Date: 12-b <br /> Date; Contractor; <br /> Signature: - Titlo, <br /> Printed name: <br /> O ERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty*of perjury one of the follcvAng 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,forthe performance of the work for which this permit is issued. <br /> et--I have and will maintain worker?' compensation insurance, ®s required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is IAsued, My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Poi6ey Number:` /6 6 <br /> I certify that in the performances 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'compensatlon laws of Californlas, and agree that if I <br /> snould become subject to the workars' compensation provisions of Section 3700 of the Labor Code, I Shsll <br /> forthwith comply with'hos revisions. <br /> Expiration Date: - i Signature: <br /> Z�I Printed Name; �-•-- ' u 8. <br /> WARNING: FAILURE TO AECURE WORKERS'COMPENSATION COVERAGE la UNLAWFUL,AND SHAD_SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLUARS <br /> ($100,000.),IN ADITION TO DHE COST OF <br /> OF THE OR COMPENSATION, INTEREST,ATTORNEY'$FEES,AND DAMAGES AS <br /> PROVIDEDFOR IDN SECTION <br /> AUTHORIZATION FOR 0TH THAN C-57 SIGNING PERMIT APPLICATION <br /> I, ^� �,_ /,, J �/ - / _ (eignature ofC-57 Ifoensed authorized representative), <br /> hereby authorize(printn0mo" I <br /> to sign this Son Joaquin County Well Permit Applloptlon on my behalf. I understand this authorization la valid for <br /> one(1)year and Is limited to the work plan dated on the front page of thio application, <br /> oian>o.m An I <br /> k* TOTAL PAGE.03 ,N <br /> DEC 23 2024 14: 19 5306682429 PAGE.02 <br />