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(signature ofC-57 licensed authorized representative), <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: 4-3(-A-/ Wa-b--1160 •ed PERMIT SR#: 00 26 ?ee2 <br />eAevrzyrt._ ,5-/Dcicip 1.-2.— <br />LJCENSED 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 Piofiessions Code and my license is in full force and effect. <br />License*: ‘05-& 6 /0 7 Expiration Date: /0/3//0 <br />Contractor r(91 9/ (/7 1--/A <br />k)tgAZ <br />Printed name: Th ta.)(Z- th? <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penally of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. <br />_Zhave 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: Tha cs; Policy Number: WC-- a- / S-19 5-2' <br />Zcertify 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 />Printed Name: Mtn/ <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 />PR*, • - • r in SECtION 706 OF TH BOR CODE. <br />1 <br />hereby authorize (p nt namelf4:(0.-61.PL Grp/Le/1 A e° -54 <br />to sign this San Joaquin County Well Pennit Application on my behalf. I understand this authorization is valid for <br />one (1) year and ts !Mined to the work plan dated on the front page of this application. <br />5-17-2000 <br />Date: -7/0 <br />Signature: Title: /2'1 <br />Date: 7/C2-7/0 / Signature: <br />95?cl <br /> [o-Lz-Tnr !NE0 ElE !'oui '6uT;sai 5LITTTTJG HaJD :A9 1.ues