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06/17/2005 11: 41 2094658773 SPECTRUM EXPLORA ON PAGE 03 <br /> OR/17/2(05 11 '22 FAX 415459056• I4EST RAV BUILDERS 003/000. <br /> San Joaquin County Environmental H alth Department <br /> ��Unit <br /> tI�IV Well Permit Application Supplement <br /> JOB ADDRESS: I ! Atti PERMIT SR#- (�6 <br /> LO;.--3 ,Qu <br /> LICENSED CONTRACTORS DECLARATION (LCQ) <br /> I hereby aff rm 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* C�S� 512Z�og ExpiratlonDete: q6o fon <br /> Date: LD Contractor dU LOQ u v h <br /> Signature: \ y� Title: r d'1 <br /> Printedname: <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 370D 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 forwhich this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are'. <br /> Carrier:�, UW o l�YC I- ld- Policy Number: &0 <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 CaGfomia, and agree that'd I <br /> should become subject to the workArs'coion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with hose provisions. <br /> Expiration Date: 1 6(Q Signaturo: <br /> Printed Name: L w C e <br /> WARNING:FAILURE.TO SECURE WORKERS'COMPENSAT:'JN COVERAGE IS'JNLAWFUL,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 COPE. <br /> AUTHORIZATION FOR OTHER HAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofG-57 licensed authorized representative), <br /> hereby author<rs(print name) <br /> to sign this San Joaquin aeunty Well Pe pilcatlon on my behalf. I understand this authorlx260n is valid for <br /> i <br /> one(1)year and to limited to the work plan date .\he front page or this oppllCetiOn. <br /> 8.29421 MI <br /> situ 29-02-001 <br /> 6rvroa <br /> OG/17/2005 FRI 11 :34 rTX/RX Nil RRgFI rain.. <br />