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uo to Anna 1k9:b4 5307873371 VANNUCCI TECHNOLOGIS PAGE 02 <br /> San= DECLARATION <br /> rtment Unit IV Well Permit Application Supplemental <br /> JOB AD _PERMIT SR# <br /> OI :S DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions ,f Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and wy license is in full force and effect. C <br /> License#: 0 )Y 74 O _ Exp Date: -J_n_ - 2-00 n <br /> Date: op ��2/ 1,;26 ) Contractor._` _ <br /> Mil/rw r.`C�Lp in f nrf.ct <br /> Signature: _( 1'f_(L Tip O1.) l <br /> Print Name: L / ✓i l , , <br /> WORKER'S COMPENSi,TION DECLARATION <br /> I hereby affirm under penalty of perjury one of the folio,,/Ing declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> /J permit is issued. <br /> I have and will maintain workers' compensatiol insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work fc which this permit is issued. My workers' <br /> compensation insurance carrier and policy nur hers are: <br /> -`7 QZLtr- COmpC��S0.�iQ'� ' I <br /> Carrier: Fn­Lg3OnCq t'rr%c Policy N:imber: (��?��`t — �_)nn» <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that it I should become subject to worker; compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signatul,): <br /> Print Nan -: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION CONT,.AGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,I V ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNF-Y'S TEES, AND DAMAGES AS PROVIDED FOR If,,SECTION 3706 OF THF_LABOR CODE. <br /> ALITHaRt�AT:flN FOR 011 HER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, « j/a wN o_' (sigr iture of C-57 licensed authorized representative), <br /> hereby authorize (print name) _ i C�__.._/!le Lcoct___......_-.-- — __. 'to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the'Front page of this application. <br /> R/21I/02MI <br /> EMD 2MI 11/.Wr WELL PERMIT APP <br />