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05/09/2005 12:45 FAX 919R53222Z The RETEC Group Inc, f�002/003 <br /> San Joaquin Courtly(Environmental Health Department Unit IV Well Permit Application Supplement <br /> 0.3 <br /> JOB ADDRESS: ;3�)/S l(��y hr �PeRAAIT sRJ�: <br /> LICENSED CONTRACTORS DECLAMATION (LOW <br /> I hereby affirm that I am licensed under the provlslons 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 t. 406 56 Expiration Date: <br /> Date: S^IO'05 Contractor. ,1 EG P1V\@�^,1Cr,���or�niw <br /> Signature: uti __Title:Cn po,,4�S c av <br /> Printed name: I ,4 t) <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-Insure for workers' compensation, as provided far <br /> by Section 3700 of the Labor Code,for the performance of the work for which This pernh is issued. <br /> I have and will maintain workers'compensatlon 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'oomponsatlon insurance <br /> carrier and policy numbers are: <br /> Caviar- S{ ="\P 144 j PollayNumber. <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'cdmpsneation laws of California,and agree that If I <br /> ahould become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall <br /> forthwith comply with thoam provisions. <br /> Expiration Date: 0^` - L005 Signature: <br /> L1 <br /> Printed Name: G. O A IIVIS4>a <br /> WARNING:FAILURE TO SECURES WORKERS'COMPENSATION COVERAGE.13 UNLAWFUL,AND SHALL SUSZCe r <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> I51Go,oaa.},IN ADDITION TO THE COST OF COMPRNSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37W OF THE LABOR CODE. <br /> t AUTHORIZATION FOR THAN C-57 SIGNING PERMIT APPLICATION <br /> WiInature&C-67 licensed authorized ropr,errlattve), <br /> hereby a tharlxe(print narm) <br /> to sign this San Joaquin County Well Porth Applimflon an my behalf. I undetabtnd this authodradon is valid for <br /> one(1)year and is limned to the work plan dated an the front page of this applloatlon. <br /> 114"21 NI <br /> CdZZrlm4 <br />