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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: --ZY1- ii PERMIT PERMIT SR#: <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 #: S/17/ 76 D Expiration Date: <br />Date: 3/P1 0 -* Contractor: 1t44.) (AC-1 i ec 1\ AiC lif) / C-S <br />i <br />Signature: 141,tte:_, (4 - Title: Ow r•J 612, <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />I haie 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: ii4Te _fr-G"•4 0 <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: 3///0E, 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, 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 />hereby authorize (print name)K-2)/vi3oe_ jer-{ /A1(' ./ <br /> <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand thls 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 />Printed name: pet /Jetty a c?—' <br />Policy Number: - <br />/JAL- - <br />a/114- aa, <br />0 3 /2 4/2007 04:25 5307373371 <br />VANNUCCI TECHNOLOGIS PAGE 03 <br />RI-ID 29-02-001 <br />6/22/04 <br />RECEIVED TIME MAR. 29, 7:18AM