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09/08/2006 15:48 JlbbJbti 01 <br />„u b• lir. .IVVV 7 VL"" nu�all ucU UCVL11 <br />IIYI111111CI1td1 <br />J A I A 1, <br />San Joaquin County LrIvironmental Health Department Unit lU Well Permit, Application Supplement <br />©B ADDRESS"it 5 w b3� 5 (.�'P PERMIT 5R#: Oo`CS 21 4 <br />LICENSEE) CONTRACTORS DECL.AIZ.ATION (!.C—QJ <br />hereby affirm that 12m licensed udder 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 />_{cense - f <br />J I 10_ Expiratlon Date: ' 3 1- <br />#: �j++ <br />Date: [ I a Con <br />Signature: _ Tift <br />Printed name'�� <br />WORKERS' COMPENSATION DECLARATION <br />I hereby aMrm under penalty of pequry one of the follewing declgrations. (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 />i have and vAtl maintain workers' compensatlon insurance, as required by section 3700 of the Labor Code, <br />for the performance of the Work for which this ptrrnt is issued My workers' compensation Insurance <br />carrier and policy numbers are, <br />carrier- A'1yt A+ f O KL A Policy Number�1 la' E--Vj!�; 3 O G' - <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 />sheuld bdoome subject to the workers' cosation provisions of Sec' n 3700 of the Labor Code, I shall <br />forthwith comply with those prav9sions, <br />Expiration Daae -J W 0 Signature �L ,J <br />Printed Name'; <br />WARNING-. FAILURE TQ SECURE WQRKERSI COMPENSATION COVERAOF 18 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINEs UP TO ONE HUNDREO THOUSAND COLLARS <br />(12OVFOR N SION +000.) ON HE T 03OFHE COMPABOR C0ATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />AUTHORVATION i=A OTHER THAN C-57 SIGNING PERMIT APPLiCATION <br />ofc-6T1teensed authorized mpresentatfveb <br />hereby authort" (print <br />to sign this Earn 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 en tate front page of this application. <br />EM 29-02-tol <br />6=04 <br />