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01/09/2006 14: 50 5102374 PRECISION SAMPLO PAGE 02/03 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application/Supplleempent7 <br /> JOB ADDRESS:/Cm (l, PERMIT SR#: C06Y <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70u0)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#:�_6� L <br /> 16?i Explratlon Date: I X71 O(,a <br /> Date: ' D( Contractor_yII !� <br /> /IGiIDIJ r-1� �L <br /> .✓ �Iki• <br /> Signature: Title: _X ��(E M(�62, <br /> Printednamel _ � 141ThcY•t��1� ___ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm tinder penalty of perjury one of the rollowing declaratlons: (CHECK ONE) <br /> _I have and will malnlaln a certificate of consent to self-insure for workers'compensation,as provided for <br /> /by Section 3700 of the Labor Code,for the performance of die work for which[his 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 performance of the work for which this permit Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier; L1!' Policy Number; ,/ WL2 �3�10�2331 OZ5 <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 manrwr so as to become subject to the workers'compensation laws of Califarnla, and agree that)t I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions <br /> Expiration Date:�ft' Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SI TALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SEcTION 3706 OF THE LABOR CODE. <br /> AMTAOI R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> zqq (signature ofC 557 licensed amhorl7.ed representative), <br /> hereby authorize(print name-JJ <br /> to sign this San Joaquin Cnunty Well Permit Application on my behalf. I understand this euthorization is valid for <br /> one(ti year and i6 limited to the work plan dated on the front page of this appllcatlon. <br /> @HD 14-0711UI <br /> 6/72n14 <br />