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DEC-23-2008 04:08P FROM:ENPROB 15305892230 T0:19169292742 P.2 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 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 <br /> Division 3 of the Business and Professions Code and my I[cense Is In full force and effect. <br /> License#: �, �� � Exp Date: <br /> Date: C) Contractor: � b �.�I vwu� /��'' <br /> r <br /> Signature: Title: 04v1y6r <br /> Print Name: 2),K//!/Jf O� <br /> WORKER'S 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 <br /> provided for by section 3700 of the labor Code,fo r the performance of the work for which this <br /> permit Is Issued. <br /> �ve and 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.. -ro,J D 1-1 011cy Number: ,^ <br /> I certify that in the performance of the work for which this permit 19 Issued, I shall not employ any <br /> person In any manner so as to become subject to the workers'compensatlon law of California, and <br /> agree that Ifl,should become subject to workers'compensation provisions of S ectlon 3700 of the <br /> Labor Code, f shall forthwith comply with those provisions <br /> Exp B Date: l J _ ��° I Signature; <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUSJECTAN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNM FEES,AND DAMAGES,AS PROVIDED FOR IN SECTION SM OF THE LMOR CODE. <br /> AUTHORIWION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, 1J�s✓ J (signature of C-67 licensed authorized representative), <br /> hereby authorize(print name) �c-h Ct yr d Ruic a;A/S k Z ERYA 15A �/�-E� ,to <br /> sign this San Joaquin county Well Permit Application on my behalf, 1 understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> EHD 2941 1115MT WELL PE RAST APP <br />