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iiereby authorize (print na <br />kw) ( 10/ cood <br />/14 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplen,.. <br />JOB ADDRESS: / 2, SO /1) • 141/ I-8 0 W cir"ILVERMIT <br />LICENSED 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 Professions Code and my license is in full force and effect. <br />License #: g / s-Y Expiration Date: 6 - 3 - <br />Date: Ar) /- 6.3 Contractor: '1/_17t4 A-1-4c.cr.46. 4,Li3 14)&esr <br />4/( Title: Crwen.41._ <br />/,(t> Printed nan}e1IIIIIt ct4A-71-4 <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 />Carrier: / it-r 1---61,0 /vs • Policy Number: 2 14/ 6V/A-1 ""? / 3 / <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 ..or-Gede, I shall <br />forthwith comply with those provisions. <br />Expiration Date: 0 q- 6/- 6 Signature. <br />Printed NameK--Z cri#47tio <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 />PROVitiED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR CITHEITiq-7-1AN C-57 SIGNING PERMIT APPLICATION <br />Signature< 6) • <br />(signature ofC-57 licensed authorized representative), <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 />EHD 29-02-001 <br />6/22/04