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11/5/2008 12:25 7073749 . PAGE 02/02 <br /> r <br /> San Joaquin County Environmental Health Department Unit N Well Pennit Applicationsupplementa <br /> JOB ADDRESS: 2481 rn5h I ree..� F S 4,_PERMIT SR# �1pp5 LtiC / <br /> LICENSED CONTRACTORS DECLARATIONL{ CD) <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 cede and my license is in full force and effect. <br /> License#: l Ub--+- q Exp Data: �' —,3A - O <br /> Date: IU/Sc>/Ob , Contractor: <br /> Signature: <br /> Flint Name: . <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the foflowing 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 /> 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 /> Carrier:�-ThC)YTJ P(1 (]A Policy Number: QAA -00aO a3 <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 Callfomia, and <br /> agree that It I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I/shalll forthwith gomply with these provisions. <br /> Exp. Date: )b-M-04 �+ !/ Signature: <br /> Io-Of-09 <br /> Print Name: <br /> WARNING:FAILUPF TO SECURE WORKERS'COMPENSA'MON COVERAGE IS UN' UL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 0100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY's FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODe. <br /> r•���� AUTHORIZATION FOR OT ER THAN C-57 SIGNING PERMIT APPLICATION <br /> 'e IA)t�.d = (signature of 0-57 licensed authorized representative), <br /> hereby authori (print name) t`rN a, to <br /> sign this San Joaquin county Well Permit Application on my be If. 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 /> Sr29lOT1M7 <br /> EHD]Pat nasal WLLFERWAr <br /> zo/SB 39dd 3T117O ON sn.LV 1S 90099L9005 50:£L 809z/0E/(3T <br />