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I 1 <br /> Apr 20 05 11 : 30a p. 4 <br /> San Joaquin Cou�n(tyy Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:SVG dE 1'Iw 1 2- �M -F/02 PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD) <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 is in full force and effect. <br /> License `:ICS �(�-T�bJ /rExpirailon Date: l <br /> Date: T z Cantr r. <br /> Signature: Title: FcyYfOI> <br /> Printed name: F FU/�PF <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> ave and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <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 /> career and policy n mbers re: <br /> <br /> <br /> I certify that in the performance of the work for which tis 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 provisions. <br /> Expiration Date: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'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,ATTORNE'f'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTH I TIO R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature ofC57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application an 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 /> 8-29-02/MI <br /> EHD 29-02-001 <br /> 6/22/04 <br />