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OCT-04-2006 WED 1124 AM GEOMATROONSULTANTS FAX NO, 559 26431 P. 03 <br /> San Joaquin County Environmental HealthDepartment UnittV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) f <br /> f hereby affirm that 1 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 /> License#: 'f � "� Expiration Date: <br /> Date (67 contractor: G L <br /> Signature: , ' -- Title: <br /> Printed name: ckyn , \0�u yn <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> �--I 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: 1— <br /> Carrier: A� P-I�Li I, ` Policy Number: i35 4 I <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in i <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 /> �z <br /> Expiration Date: i- S gnature: <br /> Printed Name: A <br /> i 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 /> 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 OT14 THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> 7 <br /> hereby authorize(print name) I n� 1 N <br /> to sign this San Joaquin County Wall Permit Application on my behalf. I understand this authorization Is valid for I <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> Fret 2a.a2•nui <br /> &Mall <br />