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, <br /> APR 30 2004 10: 14AM P LASERJET 3200 10• 2 1 <br /> RPR-30-2004 10:17 CRMBRIR 1707 935 6649 P.02,,02 <br /> i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> / <br /> JOB ADDRESS: n&. D ( Avc' PERMIT SR#: <br /> risz � <br /> LICENSED CONTRACTORS DECLARATION (LPD1 <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 lain full force and effect <br /> t <br /> License#: GS 7 S�e�GS/6� —Expiration Date: / At Ali 6 j <br /> Date: Contra <br /> 1 !� <br /> Signature: // Tltleil�fit"/r7oiro <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> 1 have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> XI 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 /> ` 1 <br /> Carrier: 14zr/GPolicy Number: 7dwa/ 90?z;7 <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 provision& I <br /> Expiration $� Zf�r, Slgnature: <br /> Data: � T <br /> Printed Name: <br /> I <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100,0011.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37D6 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C•67 SIGNING PERMIT APPLICATION i. <br /> I, !signature of C•57 licensed authorimd representative), <br /> hereby authorlas(print name) <br /> to sign this San Joaquln County Welt Permit Application on my Dena". I understand this authorization Is valid for <br /> one(1)year and Is fimhed to the work plan dated on the front page of this application. <br /> 3.19-031 MI <br /> TOTAL P.02 <br /> r. <br />