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May. 7, 2007 2:OOAM n > GROUP SERVICES INC. No. 0447 P. ? <br /> i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> i <br /> JOB ADDRESS: PERMIT SR#, ! <br /> l <br /> LICENSED CONTRACTORS DECLARATION L(_ CD) I <br /> hereby affirm,that I am licanSed under the provisions of Chapter 0(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#._ ��� `F _Explratlon Date: l / 7� <br /> Date: S - Contractor. <br /> i <br /> Signature: Title: r/ <br /> Printed name; (,— <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 work®Y'9'oompensatlon,as provided for 1 <br /> by Section 3700 of the Labor Code,for the performance of the work for which ths-permit is issued. <br /> I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> ___ ctifor the performance of the work for which this permit is issued. My workers'compensation insurance i <br /> carrier and policy numbers are: I <br /> Carrier: - 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 California,and agree that if I <br /> should become subject to the workers'compensatlon provisions of Section 3700 of the Labor Code, I shall <br /> folthwlth comply with throe provisions. <br /> Expiration Dana: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKER5'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU13JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED"THOUSAND DOLLS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAQP�AS <br /> PROVIDED FOR IN S>=CTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (algnature oIC-67 licensed authorized representative), <br /> hereby 6atitufte(print name) <br /> to sign Oils San Joaquin County Well Permit Application an my behalf. I understand this Authorization i9 valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-07/MI <br /> >�ID X9-02-001 <br /> t4!.d7d04 <br />