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IU: eja Wayne Woodward <br /> 02/24/04 TUE 10:11 FAX 916`"'792900 -- 1 -707-374-!5677 MS `— P- 3 <br /> 01/29/2004 10:24 2094elmod33 `so, 003 <br /> FIFTH FLIM <br /> PAGE 03 <br /> San Jo8quin County F-rivironmental Health Diepartment:Unit IV Well Permit App)ic-Wen Supplement <br /> J OR ADDRESS: S-0 I W- way,.. L n. PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Businessand Professions Code and my license is in full force and effect. <br /> License 9 &—Q0 q C- 5� Expiration Date: 16 <br /> Date: '- /! Contractor, l ieA <br /> Signature- Tlfdo of le -� <br /> Printed name' A/ <br /> WORKERS'COMPENSATION DECLARATION <br /> 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 Latior Code,for the performance of the work for which this permit is issued. <br /> i )r—I have and will maintain workers'compensetlon 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 we:pvr C ti tE <br /> Carrier: �-I-�A�'t, ,n r( Poney Number: <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> 4 any manner!.o as to become subject to the workers compensation laws of California,and agree that if 1 <br /> I should become subject to the workers compensation provisions of Section 3700 of the Labor Code, t shall <br /> forthwith comply with <br /> /those provisions. <br /> Date: y-Q`9 SignatufQ: <br /> Printed Name: A.J AjtC'j <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL_ANIS SHALL SUBJECT <br /> AN E11PLOYI=R TO CRIMINAL-PENALTIES AND CIVIL,FINES UP To ON2 HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION.INTERSST,ATfOFWEY'S FEES,AND DAMAGE3 A5 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> /AU,THORIZA/TION FOR OT�I�R THAN C-57 SIGNING PERMIT APPLICATION <br /> I. _W A f i<6/ �1//�b/7kJ�4Q� _ (signatum ofC-67 Ileensed authorized representative), <br /> jhereby authorize(print name) <br /> J <br /> to sign this San.losquin County Well Perim it Application on my behalf. 1 understand this authorlratlon is valid for <br /> one(1)year and is limited t4 the work plan dated on tho front page of this application. <br /> 8.29-02 1 MI <br />