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FROM : West Hazmat FRX NO. : 191663EE613 Mar. 06 2001 0E:40AM P1 <br /> 0:605/01 MON 18:27 FAX 1 91#1 0430 SECOR-SA(RAMENTO • Z002 <br /> 114/14/200 12:25 209466343i <br /> FIFTH FLOOR PAGE 04 <br /> count 5n'vironmgptal Health'SerYYca6; Utilt lY Wgll pterrnif Apphi 0>uan Supplement. <br /> �I y' <br /> San'Jo <br /> ,1QB A[�ICIRES;�,,� <br /> Srac�rr''�l. <br /> LICENSED CONTRACTORS DECLARATION W;P) <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 licen$e is in full torco and effect. <br /> S q Expiration Date' - O/- 3/ .-P 3 <br /> License* Y.__. �—_.___—�— <br /> l�/ /Tit2r..t i��Lu,f <br /> Date7nam <br /> 03-oL -0 <br /> Contractor: _-�._� <br /> n --- Title�2 E 610 <br /> Print <br /> • +n-Y+q ortt{LlL1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> LI'satiOn, as <br /> Section 3700 of the Labor Code.ffor thte af e p perforsent mance at the work fo-insure for rkwhichothis permit is issued.vidtid for by <br /> I have and will maintain workers' compensation insurance, r+s required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers cnmpc�nsaUon Insurance <br /> carrier and pop numbers are: fo yaEya `�B/K S�v26o e <br /> �j,ta�S /�S - Policy Number: <br /> Carrio <br /> 1 certify that in the performance of the work tar which <br /> this Pensationrmit is slaws of Cafitbm aE& I shall not e and agree that YlOY any irl In <br /> any manner So as a beoorne subject to the workers' came <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forMwith comply with those provisions. <br /> Date: <br /> -6 6 <br /> �a <br /> Printed Name:, _ <br /> AN EMPLOYER FAILURE CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRI D THOUSAND DOLLARS <br /> UEUECT <br /> PROVIDED FOR IN IN I SECTION 37E .O THE OF COWEABOR CODGON,INTEREST,ATYORNEY'F FEES.AND DAMAGES AS <br /> / /)Gr p/lR-r0 j)"W 7 r _ (C-57 licensed authorized representat1 1.hereby <br /> authorize <br /> to sign this San Joaquin county Well Permit Application on my behalf. 1 underxtand this authorization is valid for II <br /> one 1 ear and is limit®d to the work Ian dated on the front a of this a ptic8tlon- --- -. -- '_-J <br />