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RPR-10-2006 04:59P FROM:ENPROB <br /> ., ., 15305892230 TD:12099480621 <br /> 04/1.0/2006 14:00 fA% • P.2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Sae S 2-61S14US G+ PERMIT SR#: <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 /> LicenseLicense# 5 "� o' 1444 607 Expiration Dale: ° (1'Z,04C <br /> Date: Contractor rnoOr <br /> Signature: Title: OWAZ.✓ <br /> Printed name: _:?,✓wi r OT <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. (CHECK ONE) <br /> 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. <br /> 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 <br /> carrier and poilcy numbers are. ) <br /> Carrler:�til� CLIA-. Policy Number: (W7113T 343ZWrL <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 if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: 10111016 Signature: <br /> Printed Name: z✓ <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 HE THAN C-57 SIGNING PERMIT APPLICATION <br /> I, �LiN O O C' ( ylyde signature ofC-67licensed authorized representative), <br /> hereby authorize(print name) WolcrX <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undorstand this authorizatlon Is valld for <br /> one(1)year and is limited to the work plan dated on the front page or this application. <br /> 5-29-02/MI <br /> END 290^001 <br /> 6%22' 4 <br />