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08/1412002 16 18 2694683433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: , 03650 saw wrY 31- PERMIT SR#: 0 " <br /> �r.2.4C P. eX 96037Z <br /> I LICENSED CONTRACTORS DECLARATION (L_ CDl <br /> 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 /> CQSS14jC0.4hC qr_ <br /> License# 517(o 417 CS 7 H Jr, Expiration Date 040 30 D03 <br /> Date 09,/0q /c,4)"7 / Contractor Greo+ I, ls-' 61-1,1111114 , C. <br /> Signature Title:. MCjnOgCr f <br /> IPrinted name. A gins©_ <br />' WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> 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 /> -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 /> ICarrier cSfiak TnS Policy Number: 000 305 –02- <br /> I <br /> 2- <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 Cafifornia, and agree that if I <br /> I should become subject to the workers'compensatio provisions of Section 3700 of the Labor Cede, I shall <br /> forthwith comply with those provisions <br /> Date. O2�04/� Dau Signature. <br /> Icarnes <br /> Printed Name: A <br />' WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE Ig 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) iRoberf A +d en h u Sr h <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 /> 1-25-021 Mk <br /> I <br /> 1 <br />