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FROM : ResonantSonicInternational FAX N04 : 5306682429 lov. 04 2004 05 : OOPM P2 <br /> San Joaquin County Environmentalflealth Department Unit IV Well .Permit Application Supplement <br /> JOBADDRES34 1 (10 f6ogy iniffak PERMIT SR#0 <br /> LICENSED CONTRACTORS DECLARATION (LQP) <br /> I hereby affirm that I am llconspd under the prgYlslorls of Chapter 9 (commencing with Section 7000) of Llivl�ioh <br /> 3 of the 13uslnes5 and Professions Code and my license is in full force and effect. <br /> License a -kx3 tf Expi,ratlon Date; 1 * <br /> Contramtor, <br /> Date: <br /> Signature; TRW <br /> Printed home: '7Y <br /> WORKEAWCOMPIENSIATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decier2tiohs: (CHECK ONE) <br /> P <br /> I ha�e and will maintoln a carlificate of consent to selfalhoure for workers' compensation , as provided for <br /> by Section 0700 of the Labor Code, tr the performance of the work for which this permit is issued. <br /> I have and will maintain workers' compensation Insueance, as required by Section 3700 of the Labor Code, <br /> for the perfonnanco of the work for which this permit is issued. My workers' componsation insurarice <br /> carrier and policy numbers atet <br /> Carrier,, .. PolloyNumber: <br /> I certify that in the perrormahce of the work for Which this permit is issued, I shall not employ any persE)n In <br /> any manner so as to become subject to the workers, Dompensation Iowa of Ultilfornim , and agree that If I <br /> should become subject to the workers' compensation provisions of Bodon 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Dato* ' I'li Signature, <br /> Printed Name , <br /> WARNING , FAILURE TO SECURE WORKIRRS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHAI.L St.113JECT <br /> AN EMPLOYrzk TO CRIMINAL PENALTIES AND CIVIL VINPHS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (II100poolls), IN ADDITION To T14C COST OF COMPENSATIONP INTEREST, ATTORNEYIS FEES, AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3106 OF THE LA115OR CODEt <br /> AUTHORIZATION IFOR THAN Cw67 SIGNING PERMIT APPLICATION <br /> r1mad representative), <br /> (signature cfCm67 licensed autho <br /> her by atitharize (pr t fl3m(?) bt� �- I I <br /> to sign this ger, Joaquin County Well PaVmlt Application on My behalf, I understand this akith9rixodon Is %rolld for <br /> I <br /> one (1 ) year and is limited to the work plan dated on the front page of this applIcationm <br /> Bk2M2 I MI <br /> 914D 29h02401 <br /> 6/2=4 <br /> 21d 0170M 1 7171MCIZ;3NI WH9e : TJ V002 ' V * AON . .� <br />