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U s • <br /> U <br /> USan Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 20 J J 1t2LhjP-6�jir. PERMIT SR#: <br /> 4MI (I+ 95,263 <br /> LICENSED CONTRACTORS DECLARATIONLI CD) <br /> , ) I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divlsl0n <br /> 3 of the Business and Professions Code and my license Is In full force and effect <br /> ULicense# _70�2S!Ah Expiration Date: al IDS <br /> Dale: 1221 lO4 Contractor: TEG,- Nor7tLern (_ra�i ay Z.G <br /> Signature: Title:_ CFO <br /> 1 Printed name: L-6 JnnsSoa <br /> ' 1 WORKERS' COMPENSATION DECLARATION <br /> J I hereby afllnn 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 /> J 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 /> llI for the performance of the work for which this permit Is issued. My workers'compensation insurance <br /> _7 carrier and polity numbers are: <br /> 111 Caller._� pL 00 Policy Number. I G4 0(,03 -2,CO4- <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 1 <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 Date: _Signature: <br /> Printed Name: <br /> ' 1 WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.).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 /> ,-_J AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ' l 1'--- (signature ofCd7 licensed authorized representative), <br /> Jhareby aurh.e N. orint name) Y-r: 4+ <br /> 1. to sign this San Joaquin County Weil permit Application on my behalf. I understand this authorization Is valid for <br /> 9 one(1)yearend is limited to the work plan dated on the front page of this application. <br /> J 9-29.021 MI <br /> EHn 29-02-DNI <br /> 6111104 <br /> J <br /> IJ <br />