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Mar 28 07 01 :29p Fi-i-7h Drilling <br />MAN, id, 'IUD li:14rM NUUR LAM Inti <br />San Joaquin County Environmental Health Department Unit IV Well PerrnIt Application Supplement <br />JOB ADDRESS:I4--e: id6/367,1_Aa_ 527-0 70/c)PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that 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 #: (p Ro 5 Expiration Date: 1:3/ - 6 é7 <br />iCA5CH <br /> <br />Signature ,-- Title: OW-1 <br />Printed name: 33A0 1-45 <br /> <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 by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />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:5+Ctk Comp a-n5 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 subiect to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: 7 Signature: <br />Printed Name: Yi 0 s <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAVVFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE EILMORED THOUSAND DOLLARS <br />(3100,000.), 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 />Die/V1.(1 C H (signature ofC-57 liconsed authorized representative), <br />hereby authorize (print name) <br />to sign ttlIS 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 / <br />Eno 29-o2-001 <br />6/22/04 <br />RECEIVED TIME MAR. M. 19:21PM <br />Date: .3 - -.-6 Contactor: <br />70 7-768-3571 p . 2 <br />Nu. fl5J r