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IJCT-28-2003 16: 15 FROM:PRECISION SAMPLING 510 237 451-4 TO:510 663 4141 P.3/3 <br /> 1U!.1//UJ AUO 1J_ue rAS b1U at IDU bhUAAlRlb U.3l1LAlvU <br /> San Joequin County Environmental Health Department Unit IV Well Permit gpplieatlon Supplement I <br /> [JOB ADDRESS. a�(o�.6 5"..-rK 0 ac A kL'-,, ERMIT SRO: C)P 312 33 <br /> l <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencingwith Section 7000)of Division <br /> 3 of the Business and Profesaions Code and my license is in full force and effect. <br /> I <br /> License#: '4 Expiration Date: <br /> Date: I o Z"7 0 Contractor: /4e <br /> Title: <br /> Signature: <br /> Cq J C C�S �.. ✓ <br /> Printed name: C' <br /> WORKERS' COMPENSATION DECLARATION <br /> I <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will rneintain a certificate of consent to self-Insure for workers'compensation, as provided for <br /> by Section ,3700 of the Labor Code,for the performance 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 Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance I <br /> carrier and policy numbers are: <br /> Carrier: JA-1 f��^t- Q 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 m the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT , <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100 pp(t,),IN ADDITION TO THE COST OF COMPENSATION,INTEPEST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHERTHAN C-57 SIGNING PERMIT APPLICATION <br /> I ,•^(s/i�gnature ofC-57 IiconQed authdrizrad representative), <br /> Ae horiz®(print name) _AL�C�•r' �: �_, - 1-�°"•• S <br /> to sign this San jnsquin County Well Permit Application an my behalf. 1 undermtand this authorization is valid for <br /> I <br /> *no(t)year and is limited to the work pion dated on the front page of this application. <br /> I <br /> a-26-02 1 MI <br />