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Expiration Date: 6 4/- 6 1 6 \-- Signature' 7/12,..)I ZL7( <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 />should become subject to the workers' compensation provisions of Section 3700 of the r-Gode, I shall <br />forthwith comply with those provisions. <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: /2-S-0 14// L oi-/ tJA1 crP tilfERMIT <br />qa9 <br />b itei/g, <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Di,. <br />3 of the Business and Professions Code and my license is in full force and effect. <br />License #: / sr Y e Expiration Date: 6 4- -3 - <br />Date: 4. /- 63 - 6-C Contractor: r ,z 4691-4 C't bLICA-1 ,46 A-A:Sr-14 Ar 4/4-iccfr4r-L <br />Title: Cer-serm-r— /4474 .4-4 <br />Printed nam (6, <br />WORKERS' 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 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 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 />//v • Carrier: / Policy Number: 2.1 141 6V1<' A') / 3 / <br /> <br />Signatur <br /> C. <br />Printed Namer*/ cr1rt7to <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,J )0.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROV ,DED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION F01720-THIAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize (print na & I <br />to sign this San 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 on the front page of this application. <br />8-29-02 / MI • <br /> (signature ofC-57 licensed authorized representative), <br />EHD 29-02-001 <br />6/22/04