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FROM :ResonantSonicInternational FAX NO. :5306682429 lov. 07 2005 11:47AM P2 <br /> NOV, 3. 2005 10: 50AM CON)'OR EARTH TECH NW*wl NO, 4062 P. 2 <br /> Sah Joaquin County Environmental Health Services, Unit IV Well permit Application Supplement <br /> JOB ADDRESS: Z Z l S PERMIT SR#: <br /> *4VCkJWf11 ("A <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that lam licensed under the provisions of Chapter 8 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: ��2 - 3 3 Expiration Date: ('�� f '.— <br /> Contractor: <br /> Date: _..... _ <br /> Signature: Title' Ll <br /> Printed <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit Is Issued. <br /> ?�1 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 policy numbers are: <br /> Cartier: 54�k- w __ Policy Number. <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 shell <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SEGUKE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$ UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (8100,000.), 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 /> .�. (C•117 licensed authorized representative),hereby <br /> authorize 1d <br /> to sign this San Joaquin County Wall Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> RECEIVED TIME NOV. 7. 10: 30AM <br />