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/22/2008 12:40 7073745E WOODWARD YARD PAGE 02/02 <br /> May, 21. 2008 3. 13PM anted GeoEn O onmtntal NC, 2176 P. 3 <br /> v <br /> San Joaquin County Environmental Health Department Unk W Well Permit Applit;aVon Suppieffm*l <br /> JOB ADDRESS: 22119' W; I Ili' PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION LCD) <br /> I hereby affirm that I am licensed under the provlelons of Chapter 9(commencing with section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force andeffect. <br /> license#: 1n9 7 � E xp Date: 7'-TI/– Z Q D <br /> Date: 15-- Z /— 200 Contractor: le 7,> )�:V&l c/�✓G <br /> Signature. <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (Check one) <br /> I have and w111 maintain a certificate of consent to sett-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permi <br /> is Issued. <br /> t hav9 and <br /> will maintain workers compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier: Policy Number: ' —' <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers`compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Date: Signature: <br /> Print Name: ��� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CMMINAL PENALTIES AND CIVIL FINES UP TO$700,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMACM3 AS PROVIDED FOR IN 3ECTION 3796 OF THE LABok co". <br /> AUTHIDRIZATION FOR OT R�fi�N 0-57 SIGNING PERMIT APPLICATION <br /> I, gnature of C-57 licensed authorized representative), <br /> hereby author (print name) ICC G l Com' ,to <br /> sign this San Joaquin county Well Permit Application on niy behalf. I understand this authorisation it valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 02M <br /> EH0 28-01 11MM7 <br /> WELL PEf?1.�T APP <br />