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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �303sO Soar., �,eAcY �L vPERMIT SR#: O S 0 <br /> 76 <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 /> C,�USS�ficcc,tior�� <br /> License#: 517(v 49 C57 1-116 Expiration Date: d6/ 3Gf o2GG3 <br /> Date: 08/09/0Contractor: Grpn+ (;JQC�_-1 6vi l lint Inc, <br /> Signature: Title: Oh ifimS M6n0QC(_ <br /> Printed name: ge-nSon <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _ I 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 /> V 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: <br /> Carrier:StCrle (0h2,-p>^nSc shon TnS. Policy Number: 000305-OZ <br /> -Fund <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 /> Date: Signature: —t- <br /> Printed Name: JSomes A . 8e.n50 n <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 /> I (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) gober f A Id en h (Jy Se n <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 dated on the front page of this application. <br /> 1-25-02/MI <br />