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N <br /> t w-� --� �� <br /> ZR•oZ- <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: UUO;7 P6tIC11 F� G ,-/P-- PERMIT SR # 0577965 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 61-1'2—(O?7,-�> Exp Date: <br /> Date: Q-730 1 C,)CI Contractor:CGISGG{d2 ►�1 I I 1 VLG� , h <br /> Signature: Title: �DP✓G�-�"i DY2 S GtiVIDIN <br /> Print Name: —Fon y <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 certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> / permit is issued. <br /> v I have and will maintain workers'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 /> , rr,Ae,+n GO"✓� n <br /> Carrier: �LLt cAn Policy Number: WV3 5� <br /> I certify that in the performance of the work for which this permit is 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 provisi S. <br /> Exp. Date: Or'5 O I ZO I C—) Signature: <br /> Print Name: Tpny \:TOyy-,0,t AIF <br /> t <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin county Well P4rmit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> R/29/n2/MI <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />