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`-1 nazmat FRX NO. 19166388613 <br /> 05/10/2000May 18 2808 03:09PM P2 <br /> 04:37 209µp71110 <br /> AGE STOCKTON <br /> PAGE 02 <br /> JQ� ADDRESS: 1117Y <br /> - -�—� <br /> Loam PERM, sR X22 <br /> LICENSED CONT TRACTORS ,DECLARATION <br /> 1 hereby affirm that I <br /> 3 of the Susiness am be miRdssion under the provisions of ChD <br /> and prof tssions Code) and my license C in full force <br /> Chapter 9 (commencing with Section 7ppq Of Division <br /> License #:•—�„-'�! l l and effect. <br /> Date: / Expiration Date. <br /> Contractor: $ <br /> Sionatu <br /> cn.cc <br /> Printed na �rrt —�_Title; Ne 7,,? . viJ�c <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under <br /> penalty Ofpe One of the following declarations: C <br /> I have and will f the ain a certificate of consent to 9elf,insure (CHECK ALL THAT APPLY <br /> Section 3700 Of the Labor Co ) <br /> de, for the performance of the work for Which ompensation, as <br /> I have and will maintain workers' this permit is issued vided for py <br /> for the performance of the oomPensation insurance, as re <br /> carrier and policy numbers ork for which this permit is issued. Muired by Section 3700 of h <br /> are: y workers'compensation insurabnceor Cpde, <br /> Carrier: ' i'�a.-�J"�+Cc/z-S <br /> 1 cert( Policy Number. �r b 2K U 27`i S <br /> certify that in the performance of the work for which this Permit an manner$o as to become subject to the <br /> should become subject to the workers'compensation <br /> Workers comp mit rs issued, I Shall not am to <br /> forthwith comply compensation laws of California, P y any Person in <br /> PIy Wlth those provisions, mpensatian Pruvislpns Of$ection And agree that if t <br /> Date: __gyp. <br /> 3700 of the labor Code, I shall <br /> -4 <br /> Printed Name: l2 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATIONPENALTIES COVERAGE IS UNLAWFUL,�� �~••� <br /> (5100,000.), IN ADDITION TO THE COSTCND CIVIL FINES UP TO ANO SH <br /> PROVIDED FOR IN SECTION 3708 OF THE COMPENSATION,INTEREST,HUNDRED 7HOU5 SHALL SUgJFCT <br /> LABOR CODE. 77ORNEY AND DOLLARS <br /> /f S PEES,AND DAMAGES AS <br /> I, ------- per/ <br /> authorize_ t r7 1icenee holder),hereby <br /> —of <br /> Joaquin County Well pem,ltA (consulting),Application on my behalf. I undars,tand this authoNzatlon c valid for) to sign this San <br /> and is limited fo the work Plan dated on the front pa a of <br /> 8 this a one 1 <br /> )Year <br /> •^--�.�—------��^� PPlteation. <br />