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Jul 14 06 11 : 38a Chris Fisch 707-668-4072 p. 2 <br /> 07/14/2006 09 43 FAX 12093681�r <br /> CONDOR EARTH TECH '� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 97-15,WINk,S rce-t, /�?M1✓Zf-" PERMIT SRO: <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#' r <br /> c_ C�p ration Date; <br /> ,�r � � ``i� � �i <br /> Date: Contractor. ��L'. 2�C U •Lf�--- <br /> �_ Title•..1 .�1 � <br /> Slgnaturo: <br /> Printed name Sr - <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 perfaimanoe 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 Cade, <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:, �Cf Policy Number: <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 Calirornia•and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: c signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($ioo, ITION TO THE COST OF <br /> BOR NSATION,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N N 37 6 OF THE LA <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> fry IL V,— (signature o1C-a7 licensed authorized representative). <br /> t <br /> hereby authorise(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 an the front page of this application. <br /> 6-29-021 MI <br /> DV <br /> END 29-02-001 Us (6-y'llf <br /> 6/2?/0r <br /> 00 <br /> -� rcir�r,-L.w e vmzL o-ei . use ksl�e b <br /> -Ac � 0--A�� Dev--,� r( ti\Q VN0 (- <br /> e-s tz-rl?- %W P nV1 A,\- - <br />