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May 20 2003 2: 33PM UJRONEX INC. 510 587679 P.3 <br /> 'r <br /> San Joaquin County Environmental HealthI Department JIM <br /> JW Well Permit Application Supplement <br /> JOB ADDRESS:,,?9 O5i 9 5 I*4<, ac eL- PERMIT SR#: 3 <br /> 7X,4--rq , G4 qi -�73 7G <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I <br /> I <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#:_ d S I �Il-4-- Expiration Date: A00'5 <br /> Date: 'l 03 Contractor._�) ti n-p Y)-ex . .rtr1C . <br /> Signature: �;a._ � 1-�lU Title: <br /> .r <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> l <br /> I have and will maintain a certificate of content to selr-tnsure 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 /> �Q 1 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 <br /> carrier and policy numbers are: <br /> Carrier. lry��n�.k: L7 _ i Policy Number: (v Sc <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'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature:, ,�fA.11�w-- �-� - <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND IVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMOENSATION, INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABO I CODE. <br /> AUTHORIZATION FOR OTHER i HAN C-57 SIGNING PERMIT APPLICATION <br /> I, T KL1S�tea_ 1 lYl �.t� (signature ofCZ7 licensed authorized representative), <br /> hereby authorize(print name)_ �_ I ,,� ` �� -� �'7_ d�_._.ri: <br /> to sign this San Joaquin County Well Permit App)cation on my behalf. I understand this authorization is valid for <br /> one(t)year and is Jim Ked to the work plan dated on the front page of this application. <br /> B-29-02/MI <br /> i <br /> i <br /> i I <br />