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Oct 08 01 03:37p ESA -SRC <br />06/20/2090 09:52 2094683433 <br />FIFTH FLIXIR <br />9165644501 <br />PAGE 03 <br />San Joaquin County Environmental Heafth'Services, Unit IV Well Permit Application buppierrient <br />10B ADDRr-SS: O`b \ �,� �Y�Ev c �-© Lc . _ PERMIT SR#: <br />-t-e��-tdvt, C Pt <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm, that lam licensed under t,e provisions 0` Chap:er a {ccmrnercing with Section 7040) of C?ivisicn <br />3 of the Business and Professions Cade and my license is in full force and effect. <br />�icenseI!, 6S1113 g*4- Expiration Date- A-3 A\0 <br />Date <br />t,4�-.'to\ <br />Signature: <br />Printed name: <br />Contractor: ^��G:t :Oil S4n.tQL; N'1 1NC, <br />WORKERS' COMPENSATION DECLARATION <br />herebi affirm under penally of perjury one of the fol'owing decfaratioTTs. tCViECK ALL. THAT APPLY) <br />_ l have anal wits, ma�''ttain a certificate of cament to self -insure for workers' compensation, as provided for by <br />Sectivn 3700 of the LaSvr Code, for the performance of the work for which this penn:t is issued. <br />✓ I have and will maintain workers' Compensation insurance, as required by Secticn 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. fVly workers' compensation insurance <br />carrier anti Policy numbers are. <br />Cartier: ��'�r' c/At r••,r� Policy Number:'W e. t .. 'l$�'1 -off- Z,'; 3 9- 010 <br />I certify that in the performance of the work for which this permit is issued. I shdi', not employ any person in <br />any manner so as to become subject to the workers' compensation IawS of Califtrnia. and agree that if I <br />should become subjact to the workers' compensation provi ions of Section 3700 & the Labor Code, 1 Shall <br />forthwith comply with those provisianS. <br />Date: tat-,1o� Signature• <br />Pritste+3 Name: <br />C <br />WARNING. FAILURE TO SECt11iE WORKERS, C0MPFNSAT70WC0-Er2AGE IS UNLAWFUL, AND SHALL SUBJECT <br />p,1i EtiQt OYER To CFit"!,t?tAL Pt_R&LTIES AND Ct�lIL' RHES UP TO ONE HUNDRED THOUSAND bOLLARS <br />f;900,04(1.), IN ADOIT" To THE COST QF COMPENSATION, IWEREST, A'TTORNEY'S FFES, AND DAMAGES AS <br />PROVIDED FOR Its 5ECV0N 7Td6 OF THE LABOR CODE- <br />I. <br />ODE <br />I, M\1Le� <A<eey fC-57 Ilcansed authorized representative]. hcrtby <br />atrtktorize_ N'V tt=C�w�t+AL . SC tt,:tN QsSoa s <br />to sign this San Joaquin Clunk/ Well Permit Application on my behalf. I understand this authorization is valid for <br />one 11) year and is limited to the work <br />dated on the front page of this <br />p.3 <br />