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Feb 11 05 09: 47a David Fisch 707-668-4072 P. 1 <br /> @2i11i2005 10:19 20S-579-2225 MODES70 ATC PAGE 03 <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> l <br /> JOB ADDRESS: f�' � 5. .AII�•- Ii csc��or PERMIT SR#: <br /> i <br /> f <br /> LICENSED CONTRACTORS DECLARATION (LCD? <br /> j I hereby affirm that I am licensed under the provisiors of Chaoter 9 (commencing with Section 7000)of Division <br /> 3 of the BusinI53S and <br /> /Professions Code and my license is in full force and effect. <br /> License#: Expiration Oata: <br /> Date:4-1 Cor:tractor7 Fn V I ! <br /> Signature: `��- Title: t`W -A <br /> Printed narna: ) X !k 6 1-7SCA-A <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the foilowf-ig declarations: (CHECK ALL THAT APPLY) <br /> I have and wilt maintain a certificate of consent to seirirsure nor Workers'campensation,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 1 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'campens ation insurance <br /> Carrier and policy numbers are: r-� f <br /> Carrier: trVCf CL" ��`J I'tGxl'�3Policy Number: lJ oZ 1 Oep ? n t <br /> _I certify treat in the performance of the werk for which this permit is issued, I shall not employ any person in j <br /> any manner so as to become subject to the workers'campensation laws of California. and agree that if I <br /> should become subject to the workers'comoensation provisions of Section 3700 of the Labor Code. I sha! <br /> forthwkh comply with those provisions. <br /> Date: ? ( � Signature: r-' ---� <br /> Printed Name: t/tty'i /D <br /> WARNING.FAILURE TO SEC JRE WORMERS'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 1N SECT/ION 3706 OF THE LABOR CODE. <br /> I, (C-57!licensed authorized representative),hereby <br /> authorize A 7 C <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 in Itmited to the work plan dated on the!rant page of this application. <br /> 5-17-20001 M1 <br />