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12/03/2004 15:04 2094E-71113 AGE STOCKTON „i PAGE 02/02 <br /> ian Joaquin County Environmental Health Department Unit IV Well Permit Appricatlon Supplement <br /> JCB ADDRESS: PERMIT SR#_ <br /> LICEMSED CONTRACTORS DECLARATION <br /> I he retry affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)Of Division <br /> 3 of the Business and Pncfemcns Code and my license Is in full force and effect. <br /> Lic-riseIII: 1 /D �,S_cVD 7 Eitpirauon Date! <br /> Dat:: �d'" 6 � CordDiew . /'7 4.),�y <br /> ,t 1 <br /> Prir ted name:_ :UX14 .(4 L� <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby amrm under pernity of perjury one of the following declarations: (CHECK ONE) <br /> —t have and VAR maintili n a certificate of Consent to self-"nlsure for WOrkars•compensation, as provided for <br /> ,y Section 3700 of tale Labor Ccde,for the performance of the work for which this permit Is issue':. <br /> .- have and will mainktin workers'Compensation insurance, as required by Section 3700 of the Labor Code, <br /> or the performance of the work for which this permit is issued. My workers'compensation insurance <br /> amer and policy.numoers are: /��/y� <br /> (arrier. (/�`I l/-/ S Policy Number._&'t z 0 <br /> I cartify that in the perfmnance of the work fix which this permit is issued, I st ..1 not employ any person in <br /> :Iny manner so as to bix- ime subject to the workers'compensation laws of California,and agree that iP I <br /> nhwr become suite[.:KI the workers'compensaEon provisions of SeCN7n 3700 Code,1 shall <br /> f:rthwiUl Comply with Iha.;eJ�ovisions. <br /> Eapuation Date: �[_ ignature; <br /> Printed Name; 1 <br /> WARIIING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN Et IPLOYER TO CRINNAL PENALTIES AND CIVIL FINES LIP TO ONE HUNDRED THOUSAND DOLLARS <br /> 11100,10111 IN ADIII77ON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY-S FEES,AND DAMAGES AS <br /> rPROV IDEO FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATI(;N FOR O/TH/ERTIHAN C-57 SIGNING PERMIT APPLICATION <br /> IL (signature ofC-6711censed authored npfesanMlive), <br /> Iwrebf authorize(print name_ � � �� �� <br /> to sigr this Sen Joaquin CoL;14 Well Permit Application on my behalf. I uncle <br /> this authorization is valid tOr <br /> one(1)yearand is limited to 1114 work Plan dated on the front page of this application. <br /> a-29.07 f MI <br /> EIM 19.01.nl <br /> W22/04 <br /> ,t <br /> a d SILSESESZ6 6E =ao ro Eo auSpTvp ,eW ` <br />