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�j <br /> 11/09/00 THU 12:58 FAX 1510,2568 o 0 2 <br /> San Jorquin County,Enrirenrtiental HealthSsrvlr atz,Untt IV Well pastttlt Application St+pptemeni <br /> ��� • <br /> IS700 5� 1 SM:PERMIT S • � <br /> JOB ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION L=CD) <br /> 1 hereby affirm that I am licensed under the provisionp of Chapter ti(commencing with section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Llrense 0: 1161'_1�1- _ Expiration Dole- - <br /> Date: C '' rl-f11-'► <br /> Signature: Title: Qjara63,f e l�,I ej SP1' <br /> Printed name: P,&4A of <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers'campeneation,as provided for by <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'cormpensarion insurance,as required by Section 3700 of the Labor Code, <br /> fur the performance of the work for which this permit is issued. My workers'compensatlon Inetiranee <br /> carrier and policy nurnbom are: <br /> Carrier: �n'o,/�o Policy Number; gs <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 workero' compensation 18ws of California, and agree that if I <br /> should become subject to the workers'compensallon prvvisions of Section 3700 of the Labor Code. I shall <br /> forthwithcomply with these provisions. <br /> Date; Ze <br /> 1 ♦ /O� SIOnRture_ <br /> 646 -". nt <br /> Printed Name; ���---- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COYLRAGE IS UNLAWFUL,ARID SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIE5 AND CML FINES UP TO ON8 HUNDRED THOUSAND DOLLARS <br /> 1YION TO E7E COST <br /> OF TOF f(e LA60R CODE.ON,INTEREST, ATTORMEY*S FEES,AND DAMAGES A5 <br /> PRO1G6b PQR IN <br /> I,chn` rfrnp01� (C47 licensed autharizod representative),hemby <br /> IDl./ ir1 i <br /> aydtorito � <br /> to align this son Joaquin County Well Permit Application on my behalf. 1 understand this autherlation is valid for <br /> ora(i)year and is timitea to the work plan dated an the trent Page of this application. <br /> 6.17-2000/MI <br /> d6-1:7 = £0 00-60-m01 <br /> ZO d <br />