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May, 5 2006 12:37PM Advanced GeoEnv i ronment a' <br />- <br />May. 1 2006 :19.AM, Advanc,ed GeoEnvi ronovrila o 4724 F 2 <br />(taiiSi4 <br />San Joaquin County Environmental Fleatth rtepartment Unit IV Wet' Permit Application Supplement <br />JOB ADDRESS: 132fIr' • i,• (-4;\ PERMIT SR/#: 06(40-1 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisione of Chapter 9 (commencing with Section 'MOO) of Division <br />3 of the Susiness and Professions code and my license is in full force and et. i --rj <br />License k , z4 fr... ,,if t •, btpiration Date:7- / <br />contractor M, ( i (-A El 1 -_, v , <br />, t i. <br />,, _,./ i 4,— <br />Tine: <br />,r27 <br />l <br />i.°/ <br />7 <br />PrInted name: i'l. e g44'61 VC:f /q, ttlib'lLem eft L1., g.. <br />IA/ORKERS' COMPENSATION DECLARATION <br />hereby affirm under penalty of perjury one of the foliewirci deciations: (CHECK ONE) <br />I have and will maintain a cartifiCalo cf consent re self-ineure for workers' comperisafion, as provided for <br />by Gection 370n of the Labor Code, for the performance of the work for which tilts permit is Issued. <br />X• 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 thrs permit rs4sauett. My workers' compensation insurance <br />carrier and policy numbers are; <br />CV, <br />Caren flLt. Poticy, Number: XS (./ <br />I certify that in the performanrx of the work for which this permit is issued, i shali not employ any parson in <br />any manner so as to become subiect to the workers' compensation taws of California, and agree that if I <br />should become subject to the vircrkers' compensation provisions of Section 3700 of the Labor Code, I snail <br />forthwith comply with those provisions, <br />Expiration Dute: SlignatUre: <br />Printed Name: <br />WARNING: FAILURE' TO SECORE ifIrCIRXERS` COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($11)a,ona.), IN ADDITION TO THE COST or CoMPEraisATIoN, INTEREST, ATTORNEY'S FEES, AND DAo E5 As murirIDED FOR IN SECTION 37116 OP THE_ LASOR CODE. <br />AUTHORIZATION FOR OTHER THAN C.57 SIGNING PERMIT APPLiCATION <br />itlifehc.113k, 141 11)1:— (Nigntiture ofC-57 riceosed auttieitzo representative), <br />hereby authothe (print mimic) a-e:' Gec ,S4 <br />to sign this San Joaquin County Well Permit Application on my behalf- landerstand this suthertzatiot is valid ft/r <br />one (1) yofrar and Ilmtion to flit work plan dated on 'ate front page of this application_ <br />5,29412 1 MI <br />Date- 5- 3 C.; <br />4';'" • <br />Signature: C'',.cr 44i? <br />707-44 4 -9049No. 4815 P <br />ainia4