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p. 2 <br /> LLk JN GROUP --) 18316628;79 ND.250 D02 <br /> V <br /> tf <br /> San Joaquin County Environmental Health Department Unit IV Walt Permit Application Supplement <br /> JOB ADDRESS' <br /> PERMIT SRf#: �•3���' <br /> OD 3?q 5� <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 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 Ilcense is in full force and effect. / <br /> License 9: / Jr /�� Expfrabon Date: - / 1,30!O 6 <br /> Dote: _ Cant r. '1�. �.�77'�L S S iu C Z•-' <br /> Signature: Title: y2E <br /> Printed name: I L h,— <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the foflowing declarallons: (CHECK ONE) <br /> I have and will maintain a certlficate of consent to sett-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 /> Y I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code. <br /> for the perfomlancs of the work for which this permit Is Issued. My woi*ers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. ( DA-f. - A $. Polley Number: 1_ 100`7-d 3 <br /> 1 certify that In the performance of the work for which this permft Is Issued, I shall not employ any person In <br /> any manner so as to become subject to the workers'ccmpensatfon laws of Callfomia, and agree that ff I <br /> should become subject to the workers'ccmpensaflon proviafona of Section 37 of the Labor Code, 1 shat! <br /> forthwith compiy with those provisions. <br /> Earplratlon Date: (0 Z 4 S Signature: <br /> T---- `� C <br /> PrPnead Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AI4D 511ALL SUIBJECT <br /> AN EMRLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND OAIMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> r <br /> ` (signature ), <br /> ofC-57 licensed authorized representadvv <br /> hembyauthatza(print name) i I GW cA-4!5(— r✓(J!fA2t0r l� C OR ')exhipi lFC-(Z <br /> to glen this San Joaquin County Well Permit Appilcadon on ary behalf. I understand this authorization Is vaNd for <br /> one(1)year and Is Omsled to the work plan dated on the front page of Chia appllcetlon. <br /> 5-29-02/M <br /> EiD 24 3-061 <br />