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,"wool �..al 00 2 <br /> 06/17/03 TUE 14:04 FAX 1 510 286 2588 SECOR SF <br /> San Joaquin County Environmental Heal h Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: l�v Tim- City Got PERMIT SR#: 3� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 8(commancinq with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: C-Jr 7 W4?6-r Expiration Date, / 1'3/ /0 V <br /> Date: 6 /703 Contractor:is-ace kqy /& i 1-motet¢ ` <br /> Signature: Title: Gl►'Tl010"-f-or <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARAT10tl <br /> I hereby affirm under penalty of perjury one of the following decisrallons. (CHECK ONE) <br /> K1 have and will maintain a certificate of consent to self-Insure for workers'compensation, as provided for <br /> X <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> l have and will maintain workers'compensation Insurance, as required by -ction 3700 of the Labor Cods.for the performance of the work for which this permit Is Issued. My works-<' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: 6--S/71 Policy Number: 33 d <br /> I certify that In the performance of the work for which this permit is Issued, 1 ;,tail not employ any person in <br /> any manner so as to become subject to the workers'compensation laws c.l ,,.aivornia,and agree that If I <br /> should become subject to the workers'compensation provisions of Sectio- :- no of the Labor Code, 1 shall <br /> forthwith comply withthoseprovisions. <br /> augG..i� <br /> Deb' 112 /12 Signature: <br /> Printed Name: _ Y•tT of P�� <br /> WARNING:FAILURS TO SECURE WORKERS'COMPENSATION COVERAGE Iv t11- .•„'FUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNu ,DUSANO DOLLARS <br /> (S10o.000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATT”- '7 FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR QTHER THAN C-57 SIGNING N 4:, . IT APPLICATION <br /> _1`61, C—Az ec J0cfAo/• (signature ofC•57 1! c ti sed authorized representative), <br /> hereby authorize(print narri Alai Qaean <br /> to sign this San Joaquin County Well Permit Application on ray behalf. 1 undo 'x authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this applii,- <br /> 8-29-021 MI - <br /> •d DOZE 13C213Sd-1 dH Wd90 :b EOo2 Li wnr <br />