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DEC, 16. 2004 8:57AM CqSR EARTH TECH a N0. 8416 P. 2 <br /> N <br /> San Joaquin County Environmental Health services, Unit IV Well Permit Application Supplament <br /> JOB ADDRESS: 5/0 E , bd c,4/C! `JTIjseT' PERMIT SRO: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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*'7b�:S_(0 S Expiration Date: S l <br /> /31 1 OS <br /> Date: 12- i(o-O 4 Contractor. TGG /Vo,- rAern Ciji rOcn i 2_e- <br /> Signature: L Tilla ( O <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pejury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. <br /> 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 __,J.Vge F tom j' Policy Number: 16606 93 ­10,01f <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: I Z.-i&22 Signature: <br /> Printed Name: 4g(, J- . SCvnj <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 /> (S100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST, ATTORNEY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> ,(CS7 licensed authorised representative),hereby <br /> authorize G oYG SPF <br /> to sign this son Joaquin County Wall Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application, <br /> 547-2000 r MI <br /> RECEIVED TIME DEC. 16, 9: 24AM <br />