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San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS:z.),-4urirM. 5Z, ToCie-Mts‘ (.." PERMIT SR#: CoA <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed Linder 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 #: 717 5iO Expiration Date: 31 - '3 <br />Date: 07 contractor: 40-s.te71 <br />Signature: Title: 0 p or\ <br />Printed name: k-- <br />WORKERS' COMPENSATION OCCLARATION <br />I hereby affirm under penally of perjury one of the following declarations: (CHECK ONE) <br />I have and will maintain a certlflosite Of consent to self-insure for workers' COMpensation, as provided for by Section 3700 of the Leber 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' compensetion insurance <br />carrier and policy numbers are; , <br />Carrier; Netsk-a- P.-10-k t ciA-0-1 Policy Number: <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 Labor Code, I shall <br />forthwith comply with those provisions, <br />1„. Expiration - (7/ signature: <br /> <br />Printed Name: emeSt,-(,LA.-1 /4- <br />WARNIM FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(OMNI), IN ADDITION TO THE COST OF OOMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br />JoIgnature ofC-57 licensed authorized Mpreserbtilf0), <br />hereby authorise (print name) <br /> Becky Lee <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 ls limited to the work plan dated on the front page of this application, <br />849-02 I MI <br />03/01/2007 12:47 9166385611 CASCADEDRILLING PAGE 02/DID lL ILJtVl 1VVG114CQ VCIJI.11 1/1 fUHMUULCII AU, i L <br />• <br />En 29-02-01 <br />6/22/04