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08/06/2003 10:48 916-786-0LFR PAGE 02/03 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2-9 4-7 XIAV V vc PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LGD <br /> I hereby affirm that ; 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 farce and effect. <br /> License P. G 7 0 Expiration Date: 7- �/ -u <br /> Date: 6 'U 3 Contractor: �it'/�T�Y1�N/,�2%C '7'k i ecu-� <br /> Signature: / Title: 1115� it (7c�✓a ��" c <br /> Printed name: STnT`� 8a z <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 tq self-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 /> 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: /Z S('1�6 "` ('�-/ �"f' �" Policy Number: w/bG Ci7D0 i=r'/0 3 <br /> 1 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 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: J' 3 Signature: <br /> Printed Name: <br /> WARNING: FAJLURS TO SECURE WORKERS'COMPENSATION COVERACE;S UNLAIWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1110,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR <br /> OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> � (signature ofCSI licensed authorized representative), <br /> hereby authorize(print name) <br /> J�cv�r' ! .`r.oY�LQr�G <br /> to Sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is Amitedto the work plan dated on the front page of this application. <br /> s•xa-oz r MI <br />