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FROM :ResonantSonicInternatior FAX NO. :5306682429 Lt. 01 2004 02:24PN P2 <br /> 1e/e1/2004 14:12 20946e3433 FIFTH FLpOR <br /> PAGE 02 <br /> San Joaquin County viratlmerttal Health Departme Unit IV Well I aetrnit <br /> Application SuPPIement <br /> JOB ADDRESS: I <br /> PERMI� SR#: <br /> LICENSED CONTRACTORS DECLARA ION Lip) <br /> I hereby affirm that I am licensed under the provision®of Chapter 9(com ing wlth Section 7000)of Division <br /> 3 of the Business and Professions Code and my Iloense is In full force and �{, <br /> License# E.Vratlon Date: (� - CIS <br /> Date: <br /> Contractor" /t c sn•%n-+� / <br /> Signature: <br /> r. Title <br /> Printed nariie: ���.ti. L` w• _L� <br /> LJ <br /> WORKER$' COMPENSATION DEQ TION <br /> I hereby affirm under penalty of po ury one of the following declarations- (C ECK ALL THAT APPLY) <br /> I have end will maintain a certificate of consent to"f-intDure for worke compensation, es provided for by <br /> Section 3700 cf the Labor Code,for the performance of the work for ver117 <br /> this permit is issued, <br /> l have and will maintain workers'compensation insurance,as required Section 3700 of the Labor Cc e, <br /> for the performance of the worst for which this permit Is issued. My work s'compensation insurance <br /> carrier and policy numbers are, <br /> Carrier: ��i.� . ,, L Policy Number~ <br /> certify that in the Performance of the work for which this permit is 19W , Isbell not employ any person'in <br /> any manner so as to become subject to the workers'Compensation laws of Calftnia,and agree that 9 1 <br /> should become subject to the worriers'compensation provisions of Se n 3700 of the Labor Code, I shall <br /> forthwith Comply with those provisions, 1 <br /> DAA t> c. Signature: <br /> Printed Name: a, <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 NLAWFUL,,AND SHALL SUBJECT <br /> AN EMPLOYIEk TO CRIMINAL PENALYlMS AND CMl,FINES UP TO ONE HUND D THOUSAND DOLLARS <br /> ($100,000,),IN ADOMON TO THE COST OF COMPENSATION,INTER111$T,A NEY'ti FEES,AND DAMAGES A9 <br /> PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE. <br /> I, w_ ti .4 _LJ, c.•t� - fL �,4', (signature&C-S7 licensed authorized rapr8serttAtiv®), <br /> herebyauthorizv(prl nwme)__ �•�rcII,- <br /> to sign this San Joaquin County Well P6rfiiurw1.9,'Cat1on on my behalf. l un Land this authorization is valid for <br /> ane(1)year and Is Iirr teed to the work plan dated on the from page of this applltwlon. <br /> -2"21 FAI <br /> I <br />