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P2- - 6o 24 i <br /> 0U2A- - 2 <br /> tv 003A j <br /> r1oJ yeo�- �4/ /%a4e ✓ /�� f <br /> San Joaquin County Environmental Heal apartment Unit IV Well Permit Application Supplement i <br /> JOB ADDRESS: �y 5 PAGFlG AW,- , PERMIT SR#:DSLb 19 <br /> SToCO61-4 CA RS2-P7 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 license is in full force and effect. <br /> License#: 1 (O 071 Expiration Date: 07 -31- 200 9 1. <br /> Date: l(-(5/-/0"l ContractorU110cY(7u/AR`-I� bti f�L41- ld..t.LP"y-, vie, <br /> i� tA1/�/G2T /�/�Ol Title- /karp E✓� <br /> Signature: � <br /> Printedname: CoAiGINCr E- W&)OWAteD <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _1 have and will maintain 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 the work for which this permit is issued. i <br /> ,X 1 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 I i <br /> carrier and policy numbers are: I <br /> Carrier: STATE FUAID Policy Number. 602,0229 -240-1 <br /> I <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'compensation laws of California,and agree that'd I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall i <br /> forthwith comply with those provisions. /� C . <br /> Expiration Date: 0 20a �-�Signature: zit <br /> Printed Name: "001 f(— E lAfirsDW <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL 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 /> ///AUTHORIZATION FOR <br /> OTHER THAN C-57 SIGNING PERMIT APPLICATION I l <br /> 1, 4/0- G+%cvvie.- (signature ofC-67 licensed authorized representative), j <br /> hereby authorize(print name) UAGf45 GOLDSTEtA! 072 MAIL btAG[.EOD { <br /> t <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for I <br /> one(1.)year and is limited to the work plan dated on the front page of this application. I: <br /> 6-29.021 MI <br /> i <br /> i <br /> EHD 29-02-001 <br /> 622/04 <br /> i <br />