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08/17/05 01:22pm P. 002 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:-Ripon, California PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I 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. <br /> License#: 71576217 Expiration Date: 17-- 10- O S <br /> Date: d ' I Z` ©S Contrgetor._Pit,o Soni I C Co"oa,9-Trl o✓j 6&' Axu4nicE-P&09+lc <br /> Signature: 4pl� / Title:Southwest Region Manager <br /> Printed name: Gregory Ze o ,P.E. <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: S—,trc LJ tu Q Policy Number: ( ? (O 3 (o73— <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'compenssaatiioonnn provisions of Section <br /> 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 11-31 -Q` Signature: �7 <br /> Printed Name: C, <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL 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 /> NT ORIZATINR�pTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name)' _ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> B-29-021 MI <br /> EHD 29-02-001 <br /> 9/30/2003 <br />