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APR-6-2007 09:22A FROM:ENPROB 15305992230 T0:19256024720 P.2 <br /> b9/abllnt;! Jy:Ulf ltGnbu.Gq!Zu til'- t`?Z11NttM11N1j rn rnur- ul� <br /> I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplerhent <br /> i <br /> JOB ADDRESS: �- �Li a � � PERMIT SR#1: <br /> J;� - -'-1, C4 q0G <br /> I <br /> LICENSED CONTRACTORS DECLARATION (LCD I <br /> I hereby affirm that 1 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 /> I <br /> License#: C 57 7?7+b'"-7 Expiration Date: <br /> Date:�< � - _ _ Contractor: <br /> Signature: ;- _- -Tr _Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hFrPhy affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _ I have and will maintain a certificate of consent to self4risure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code, for the Derformance of the work for which this pern2it is issued. <br /> E l have and will maintain workers' mirripen€ation insurance, as required by Section 3700 of the Labor Code, <br /> foe ifie performance of the work for which this permit is issued. My workors'rrimppnsation insurance <br /> carrier and policy numbers are: <br /> AjC uGC7° 73 43- Zoo b <br /> Carrier: <br /> �� N (�l1�CL _Policy Number: <br /> jI 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 subiect to the workers'Compensation laws of California, 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 DateO,I-07 Signature: <br /> Printed Name:_ eK//Uj <br /> WARNING:FAILURE TO SECURE WORKERS' COMPEiNSAT!OiN COVERAGE iS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY-$FEES,AND OAMA052 AS <br /> PF!O/ir:Fr)FOR IN SECT110N 970E of THE LABOR 001%. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION � <br /> I, 2`1 V15 C.-Irr (signatum ofC-57 licensed authorized ropteseritative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this author4$ation is valid for <br /> one(1)year grid is limited to the work plan dated on the front page of this opplleation. <br /> 0-29-021 MI I <br /> '?M)24.02.001 <br />