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D alk A ,c C“.9\ <br />(Ak- hereby authorize (print name) <br />(-1-441(44-1--7 .,9 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: (-It OS t\--) • uOitson c3a,4 PERMIT SR#: t 2O 5° 9 <br />StOCU-tOn • <br />LICENSED CONTRACTORS DECLARATION (LCD) <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 #: -1 0592-7 Expiration Date: 05 - t • 0-7 <br /> <br />Date: 0(4 t2.. • Cr/ Contractor: \/ <br />Signature: OCtAAA Title: °MCC rnatilacaee <br />Printed name: (Arne-A a .-Oarnarr6 <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 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />X 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 />carrier and policy numbers are: <br />Carrier: CY-0.0ii‹. Statt <br />Policy Number: <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 provisions. <br />Expiration Date: 0(0 ' 1S• 01 Signature: <br />Printed Name: Cknde).. cOainCinti <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, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature ofC-57 licensed authorized representative), <br />el v1 cl _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 is limited to the work plan dated on the front page of this application. <br />8-29-02 / MI <br />a <br />DID 29-02-oo <br />6.,22/04