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JUN. 1B. 2004 9:40AM Cj§OR EARTH TECH <br /> • N0. 5112 P. 2 <br /> San Joaquin County Environmental Health�Department unit Iv well Permit Application supplement <br /> JOB ADDRESS:.710 E, !*4&e ; lT� Sl,,./, <br /> � PERMIT SRl1: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I hereby affirm that I am licensed under the provisions or 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 M. 7o6S(o$ <br /> Expiration Date: J� 31 fls <br /> Date: 6-18—o ' contractor. -'DECC Ala-Ker T <br /> n a <br /> Signature: CFO <br /> Title: <br /> Printed name; � 9"'Q <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workors'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 /> Xhave and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance or the work for which this permit is issued_ My workers'compensation Insurance <br /> carrier and policy numbers are; <br /> C�rrier. {� Fuhd <br /> Policy Number: 166D683— Z003 <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 se 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 <br /> forthwith comply with those provisions, of the Labor Code, I shall <br /> Expiration Date;—4A"—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 /> (4100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 77D6 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Ls;�' J (signature OfC-117 awthorized reprssenttat'ive), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Applloatlon on my behalf. 1 understand this authorization Is valid for <br /> one(7)year and is limited to the work plan dated en the front page of this appllCation. <br /> U-29-02 MI <br /> F.ffD 29-02•DOl <br /> 90012002 <br /> RECEIVED TIME JUN- 18, 9 : 59AM <br />