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09/02/2008 18:56 707374`=77 WOODWARD YARD PAGE 02/03 <br /> 09/02/2008 15:06 5306Ta6e05 STRATUS NO CALIr-- PAGE 02/03 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: `(�`I I S`aI L PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed Under the provisions of Chapter 9(commencing vdth Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License4k 1(l)D7`� Exp Date- �oDQ <br /> Date: 4 Col,tractar. <br /> yy7�OLf .��,,�y� <br /> Signature: Title: / 1tf1. 0-1 _— <br /> Print Name: CEMGLA!(r i Lt2Ut OWAU <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certrfloate of consent to self insure for workers' compensation, as <br /> i provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workera'compensation insurance,as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: SMITE G-JA Policy Number: 0 0 ?-07i3 9 <br /> I certify that in the performance of the work for which this permit i9 issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 442&072 Signature: ei—; !c'/e-D wAdxxll <br /> Print Name: C,OA/CfAIJ ee,'tNo pl%WyelJ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$1 M,000,IN AbbmON TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 7706 OF THE LABOR CODE. <br /> AUTWORIZA Il THER T AN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C47 licensed authorized representative), <br /> hereby authorize(print name) II0.y �,r( iN S�'CM-t CO3,4 ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on tee front page of th is application. <br /> e/R W02/MI <br /> Er02601 1'.15IJ) 'NELL iEP.MR A=� <br />