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SENT 8Y: SPECTRUM; 4:22PM; 4858773 => "1259471390; #212 <br /> r. ...,..... <br /> if San Joa uirt Count E.....------.. <br /> � ���. .�-.. ,nvirorlmt.nta! Health <br /> County Services, Unit iIV Well Permit Application Supplement' <br /> .JOB ADDRESS_ _6,e06k"5,,b t9aln1� �f . <br /> PERMIT SR#; �J <br /> LICENSED CONTRACTORS DECLARATION (LCD) ; <br /> i hglaeby a firrn trial. I am licensed urulFr ti-at=provmions of Chaplet 9(commencing with Section 7000)at Divtstort � <br /> 3 of the Bu.sineSs al-W Nrofession� Code s,:r41 my fir;0n5e is in full force and effect. <br /> _ i <br /> Licit±sF » -� 1 .rra ....... _...... C:xpt�ation Date, - - <br /> Signature: <br /> _ <br /> Tine. <br /> —�=...��,�..,. -�....:M... �J/}I7Ditlf <br /> € Printed name <br /> at._.. ..1 '4 1d <br /> j <br /> WORKERS' COMPENSATION DECLARATION w <br /> Ii r+ere by Lathan tai(ser pemaity o! perjury tent'_of the. fvllowiriq declaration;: (CHECK ALL THAT APPLY) l <br /> i <br /> have and will rrt�tiittana�t t-t7Ruficate of consent to self-insure for workers'compersahart, aS provided fnr by <br /> or-,lion 3700 of lh7e Labor Cade,for the per°cirmance of the work for whicft this permit is issued- <br /> _ I have and will maintain warners' coaipensjlion insurance, as required by Section 3700 of this Labor Code. <br /> f+�t rl�r3 perforEttrirtcr of the wtxi� t;x rvt�!i;tt khi5 j,Lrmit iy isSUed. Loy wofkLLr5'Compensation insurance <br /> {_tarries and policy numbers art,.. l <br /> 1 � <br /> Carrie F:LZ <br /> i <br /> ° Policy NurnDer. <br /> _ I o.a ily that iri (tic perfortna ace of the woi k tor'wrtirri iltii5 phrmit is issued. I shaif not emplr y any parson in k <br /> any manner so as to become subject tv We workers' compensation laws of California, and agree that if I <br /> should become subject to the worl4ers'compensation Qrovisio s of Section 3700 of the Labor Code. I shall <br /> 1ti(1htwith Comply with those provi5iorri <br /> Date: .......1...._ LLV � 'ig ,acute: <br /> ....... - 1A�....._� ..—........... <br /> .._.. _ !: <br /> a <br /> l Printed Name: �� r <br /> WAftt4lNG: FAILURE TO SECURE WORKERS'COMPENSATION VERAGE iS UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TEEl ONE 14UNDRED THOUSAND DOLLARS <br /> (S100.000.),IN ADDITION TO THE COST OF COMPENSATION.INTEREST.ATTORNEY'S FEES.AND DA-MAGES AS <br /> PROVIDEO FOR IN SECTION 3748 OF THE L-ABOR CODE. <br /> licensed euthorizad nialltrv),herab�ll <br /> ��a�G ISG I <br /> authorize.. _ r __.V. ..,...,.. .w'` /1)1A <br /> to sign this San Joaquin County Wali Permit Appkcatidn on my behalf. I understand this suthOriZatiOv lm valid for <br /> i <br /> one it)year and is limited to 1he work plan dated on the front page of this application- <br /> 5-11-2000 1 <br /> pplication-5-11.20401 M1 _„- __ ....__._._._...._..._.... . .._ ......... <br />