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u4/ZJ/2UU1 MVN LJ: la YM <br /> Apr 23 07 12:01p Musco Family Olivewpan 836060 p.2 <br /> San Joaquin County <br /> /E Environmental Health Department Unit IV Well Permit Applications Supplement <br /> JOB ADDRESS: '`? C 5� VLR /t/Gfrd Jt PERMIT SR#: 007� <br /> ' iuul2 S,26 <br /> 06 SO73z f ^L��2e <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affnn 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 /> License#:. :22 O 9 Qt-1 &plration Date: dA,� �QQg <br /> Date' L Con CIoC ,\ <br /> Signature: Title; <br /> Printed name: O e <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of poriury 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 Lahr Code,for the performance of the work for which this permit is issued. ' <br /> V I have and will maintain workers'compensation insurance,as required by Seclion 37th of the Labor Code, f <br /> for the performance of the work for which this permit is issued. My workers'Compensation insurance <br /> .. _.__ carrier andpolicy numbers are: <br /> o <br /> Carrier , ',[tact Policy Numbor:_L7S a/Eri <br /> I certify that in the performance of the work for which Ibis permit is issued,I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Califomia,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 bete: 406061 _Signaturo: <br /> Printed Name: 66-mit, G • IC� �ev <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 /> ($700,000.), IN ADDITION TO THE COST Or COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> hLITHORIZATIIOON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> Ilsiignawre ofCb7 licensed authorizod reprosentative), <br /> hereby authorize(print name) �li/N /I�tzC <br /> to Sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan doled on the front page of this application. <br /> 3.29-0Z I NU <br /> ting ze-ni•n01 <br /> rrzyoa <br /> 04/21/2007 ZION 1:1:06 ['I'X/RX NO 779,9) x002 <br />