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p. 2 <br /> Lt- `N CiRoup 18315,;23179 <br /> N0.250 go <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application supplement <br /> JOB ADDRESS: <br /> PERMIT SR#:—00,39v�3 <br /> LICENSED CONTRACTORS <br /> ORS DECLARATICN LCa <br /> I hereby afifirm that I am licensed under the provisions of Chapter 9{commencing with Section 70()0)of[)Msion <br /> 3 of the Business and Prcolesslons Code and my 11cense is In full force and effect. <br /> LlU9ltge it _ Expiration Date' <br /> Date: Conti/ Co�rn�� <br /> Signature: <br /> Title: �ZES <br /> Prlrftd name: t hti l r< <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insura for workers,compensabon,as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is!,sued" <br /> X I have aM will maintain workers'compensatlon insurance, as required by Section 3700 of the Labor C <br /> for the performance of the work for which this permit IS Issued. My wort ers' ode. <br /> compensabon insurance <br /> carrier and polity numbers are: <br /> Cardec, rvNb Polley Number: l 00'7-6 <br /> I cartify that In the performance of the work for which this permft is Issued, I shall not OmPlOy an <br /> any manner so as to become subject to the workers'compensation laws of Callforn3a,and agree that ff I person In <br /> should become subject to the workers'eompensatlon provieloni3 of Section 37 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiratlon Date:12-L2- 0 S Signature: <br /> PrintedName., �~ J <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL.,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (i1Q0,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTO"EY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (slgnatum afC-97 licensed authorized reprwwrrtattveL <br /> hemby suthortre(print name) G W 6FL 111 21 C oR <br /> � -AlAi lrE2 41.1 <br /> to sign this San Joaquin County Well Pormh AppllcWon on my behalf. I understand this authorization In vend for <br /> ane(Z)year and Is limited to the work plan dated on the front page of this application. <br /> $-29.02 f W <br /> ERI)2542-M1 <br />