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rel I uof ZUVO <<.Ll D3CJbbz0U0z WVU tYNLUKA I iUN PAGE 03/05 <br /> 12/27/2007 13:59 5306629052 WDC EXPLORATION PAGE 03/04 <br /> DEC-27-2007 1106 fAMBRtA 1707 93!i 6649 P.M/0d <br /> San J08quln County Envlrertmental Health Department UnitfV Well PermitApplicatfat+; upplem"t <br /> JOB ADDRESS. iZ4 77 a�-.� /wt�.S(>t� ERMIT SR#.- 0530�1� <br /> LICENSED CONTRACTORS DECLARATION wccii) <br /> I hereby aftUm that I am licensed under the provioiony Of Chllpter 2(commencing vhfh Section 7ti(4)of O(visbn <br /> 3 of the Business and Professlons Code and my license is in run fora!and effect. <br /> Licence Eviration Date: <br /> Dale: Z Z? Contractor,_ 191X 9Y&a,cA�r� a 4.5rc,s <br /> Signature: Title: <br /> .� <br /> Printed name: Otauru�E F> <br /> T <br /> WORKERS' COMPENSATION DECLARATION <br /> l harel)y offirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will rnsinlatn®cterlftzte of consent to serf inmure for workers'cnmpensatlon.as ard <br /> by Ssction 3700 of the labor Code,fbr the pe�m,e�of the work for which this perrntt ie . for <br /> wr ed)vlde <br /> �G I have and will mafntain workers'compensalion insurance,as requned by Section 3700 of th,!L®bor Code, <br /> for the per1`0rrnanC0 Of the work for which this pW tgt is lesued. My workers'compensation i'rau-ante <br /> carrier Arid policy numbers are: <br /> Carrier: F?w 1�7 USI Cwt If, Z¢it[IL policy Numbor. 904-75W <br /> I certify that in the Performance of the work for which this permit is Issued,I"I moll employ itni,person in <br /> any manner ao as to become Subigct to the workers'compensation 1aw8 of Califoil?14,and agirw!fW if 1 <br /> should become subjw to the workers'cvrnpensetion provWoris of Section 3704 of the labcN Gr,Oe I II <br /> fOM W 0omply with those provialons. <br /> Expiration Data: „_SigAStUrs: � . <br /> Printed Name: <br /> WARNING. FAILURE TO SECURE WORKERS'COMPENSATION C05rrMAOE M UNLAwFUL,AND Stii>U..SUBJECT <br /> AN BMPLOTER?O CMMINAL PENALTIES AND CIVIL.FINIES UP TO ONE WJMMD THOUSAND OOLLAf4,8 <br /> (5104,t1lD.),IN ADDITION TO 7H9 COST OF COMPENSATION,INTEREST,ATTORNErg FEt ,AND DiaMIAGES AS <br /> PRMDED FCR IN SECTION 37116 OF TWE LIBOR CODE. <br /> AUTHORIZATION FOR 0 THAN C-S7 SIGNING PERMIT APPLIC,A,TKIN <br /> I' WRIISIUM o(t<.57 lieaMW autlhorltod reporsentanve), <br /> b#P*by authorize(print no") <br /> to sign thfs San.Ioaqu'.n County Well Permit Appliestlom on my behalf. I understand this authorixaticun Is v011d for <br /> onr(t I year and is limited to the work plan dater)an the fyont page or this opplioation: <br /> s-296021 MI <br /> t:NU 2'1.02•GIt l <br /> GI�Lba <br />