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FEB-26-2001 09:41 FROM:TWINING S, INC. 559 269 7126 TO:�F" 4683433 P.004,205 <br /> %86=2I £00:3'DCd 'DNI 'S 9NINIM.LCOI ££b£89b6m 1 WODD•tn uec-moo uy <br /> San Joaquin County Environmental Health Services,Unit IV Weil Permit Application Supplement <br /> JOB ADDRESS:_ 32-3 S, j�� PERMIT SR#:_ 0025 L 1 7 <br /> LICENSED CONTRACTORS DECLARATIONL( CD} <br /> 1 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 license is in full force and effect. <br /> License#n:/ 52)615:9 Expiration Date! nC B <br /> Date:A!il oL_ —Contractor: <br /> Signature: <br /> l Title: w r <br /> OL <br /> Printed name:_ <br /> a r(/4.ZYA skr <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'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> e I have and will maintain workers'compensation Insurance,as required by Section 3700 of the Labor Code, <br /> _ for the performance of the work for which this permit is issued. My workers' compensation Insurance <br /> carrier and policy numbers are: pp <br /> Carrier: ��� r:W010 Policy Number: �yf7D© Y7— <br /> I certify that in the performance of the work forwhich this permit is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code. I shall <br /> forthwith comply with those provisions. <br /> Date: ��SBO _ Signature: <br /> Printed Name: M• •ZyA).y k <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE I$UNLAWFUL,AND SHALL SU19JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> (C-57 licensed authorized representative),hereby <br /> authorize to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5-17,2000/MI <br /> co 30vd ECOSS90506 LP:80 I00Z/9Z/Z0 <br />