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APR-19-2002 13:43 MARCOR REMEDIATION INC 510 632 9303 P.02/02 <br /> San Joaggiio County Environments!Health Services, UnJt IV Well Permit Application Supplement <br /> /'f�!�:C AeW.-42"1Y'5 Sf _ .,a<.e>>�pb�• . <br /> 'JOB ADDRESS; ;7c PERMIT SRS: <br /> LICENSED CONTRACTORS DECLARATIONL(_C <br /> I hemby;affirm that,l am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division . <br /> 3 of the Busim"s and Professlons Code and my license is in full force and effect. <br /> License 0:.�,7 366-$! _ Expiration Date: ( '-���03 <br /> Date: 02 Con r. (�C�2 ��►.� ���io�, ��� <br /> Signature: Tltit'�5���5/�J�oa.��.� <br /> Printed naMr, ^jDiee(z COsr- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affinif under penalty of perjury one of the following dectarations; (CHECK ALL THAT APPLY) ' <br /> _ I have and will maintain a ceritficate of conAent to self-insure for workers'compensation,as provided for by <br /> Section 3T00.of Me Labor Code,,for the performance of the work for which this permlt Is issued. <br /> 1 have-snd,,#A 1 maintain workers'campensadon insurance,as required by Section 3700 of the Labor Code, <br /> fort*wrormance.of the-work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbere.are: <br /> Carrier. Policy Number: <br /> _f,cartify!clef in the performance of the work-for which this permit is issued. I shall not employ eir►y Person in <br /> any menror so'as to become subject to the workeW compens'atlon laws of California,and epree that if 3 <br /> should become subject to the workers'compensation provisions of Sectlon 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Date: signature: <br /> Printed Name: <br /> WARNING.,FAILURE TO SJICJJPtE WORKII'RS'COMPENSATION CDVERAGE IS.UNLAWFUL.AND SHALL SUBJECT <br /> AN EMOLDYEkTo cNNONAL"PENALTiES AND CML FiNES Up To CNC.HUNDRED THOUISAND',DOLLARS <br /> (SiOd,Ol10.),INXDDIT)aN TO THE COST OR COMPEWATION,INTSMST,ATTORNEY'S FEES,AND DAMAGES AS <br /> pitmoED FGR IN SECTION 37060F THE LAEOR CODE. <br /> G Is nature ofG67 licensed outhorlmd ieprosantatve). <br /> rr,4-'Ebel rt ` <br /> hereby suthor�sa(print namal,� t^e �''Sd1ti S u.�cc.cc�i c <br /> to Von this.3a r Joaquin County Well Pemit Application,on my behalf. t undanztand this authoet ntion ie valid for <br /> one(1).y.pw and Is limited to the work plan datad on,the froW peso of this appilcation. <br /> TOTAL P.02 <br />