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FROM :ResonantSoniclnternationle FAX NO. :53000e2429 46ay. 20 2005 09:58AM P2 <br /> 05/20/2005 09:45 2094683433 FIFTH FLOOR PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> PERMIT SR#: <br /> JOS ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION (�J <br /> I hereby affirm that I am licensed under the provisionssloe se is Chapter <br /> pte farce and effect.mmencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my <br /> License#: �_a��3 `� <br /> Expiration Date: I L <br /> Date, 3 Z� Contractor: <br /> Signature: <br /> Printed nam <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perIury one of the following declarations: (CHECK ONE) <br /> I have and will ma{ntaln 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 on <br /> 0 of <br /> he <br /> for the perto Imaintain <br /> of the work for wnpieeh this pennit s issued. My workers'cohmpensationt nsurancode, <br /> e <br /> carrier and policy numbers are: <br /> carrier: T Policy Number: --- <br /> I certify that in the performance of the work for which this permit it: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 <br /> should become subject to the workers'campensafion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Signature: <br /> Date: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURFWORKERS'COMPENSATION COVERAGF IS UNLAWFUL,AND SHALL <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARSOBJE S <br /> IN ION TO THE 37 0 DFSTHE LABOR COMPENSATION, INTEREST,ATTORNEY'S FFES,AND DAMAGES <br /> PROVIDED FOR INCODE <br /> AS <br /> 4reby <br /> HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of Gd7licensed authorized representative), <br /> heauthorsze(print am) <br /> to sign this San Joaquin County Well Permit Appllcatlon on my behalf. I understand this authorization is valid for <br /> one(1)year and is I IMlted to the wark Plan dated on the front page of this application, _ <br /> - <br />