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"' ��'�'� i�• li rKUM PRECISIUN SRMPLING TU 15592647431 P.01 <br /> San Joaquin Caun y Environmental Health Sarvicss,Unit M brat, permit Application Supplement <br /> JO' B ADDRESS; PERMIT SR#: <br /> I� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby afro that P d I CCnsed ttrlder the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of 71e Business and Processions Code and my license is in fun force and effect. <br /> 1 License#: <br /> xpirat on Date: �La 1 /O L <br /> Date: �/ Z // <br /> -- ConVOCtor_ J,4 'Ji0- <br /> Signature: <br /> Trice: C �,fta n Tr G3 lGC. .T� <br /> Printed name: C 1 <br /> ORKERS'COMPENSATION DECLARATION <br /> I harebY affirm under panatbj of pequry one of the following deataratioms: (CHECK ALL THAT APPLY) <br /> T 1 have and wilt mairdain a certificate of conffient to self-insure for workers'compensation, as provided for by I <br /> 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 Inauranca,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. M workers'corrtpertsation imatirarrca <br /> cancer and pol'icjy numbers are: <br /> Carrier. Lr_ J?�f /fit r vo Policy Number. ``i of A7( 0 7 z 3 3S o)o <br /> certify that in the portormance of the work for v*Iloh ttti6 permit is issued,I Wail not employ any person in <br /> any manner so as to become subject to the worfrers'txunpensatidn taws of Califixnia, and sgrap that if o I <br /> should become subject to the workers'compensation prwisirms of Section 3700 of the Labor Code, I shall <br /> foAhwNh comply with those provisions_ <br /> Date• 0! Signature <br /> Printod Name: GYr 'J qui <br /> WARMNG-.FAILURE TO 3E.CURE WORKERS COMPV114SATI W COVERAGE 18 UNLAWFUL,AND SHALL 5UnJECT iI <br /> AM E%IPLOYER TO CRIMINAL PENALTIES AND CngL FLMES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (51a0,OQp,},IN ADDVOON TO THE COST OF COMP"BATION,INlEeRMT,ATTORNEY'S FEES,ARID DAMAGES AS <br /> PROV67ED R IN SECTION 3706 OF THE LABOR CODE <br /> 1, <br /> mantra otC.57 NcQa ed authortned representatl . <br /> here w,40(pint nacre}. Ql"i e 4✓� <br /> to sign this San Joapeln County Well Permit App@cation on my behalf- 1 understand this authorirallon is valid for <br /> one(1)year and is limited to the work plan dated on the frmrt page of Utas applicaben. <br /> 5-17-2000 t RB <br /> Post-ir Fax Note 7671 pWc !r LY/Q pages i <br /> To G24 From <br /> ✓ d..t.I m„ t� �.. <br /> Cc/Dept <br /> Phone n Phone# TOTRL P.1 2 <br /> Pax. SSS' tG 7cl3r Fenn <br /> TOTRL P.01 <br />