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T0;19256024720 P•2 <br /> 15305892230 PAGE 03 <br /> -OCT,-18-2007 02:53P FROM:ENPROB ETIC ENGINEERING P'�� <br /> 10110/2007 14:17 19256024" <br /> S <br /> San Joaquin County Environmental i i;aWl Dsparlment Unit N Well Pernik AppgetitWn SuPP7—r <br /> JOB ADDRESS; �7�7 SCe er Jfi = PERMIT SR#: 6L 5 <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 hicensed under the provisions of Chapter 9(commendng with Section 7000)of Division <br /> ereby effnn that t am l <br /> 3 of the Business and Professions Code and my license la in full fofCe and <br /> Licensee: � <br /> e-S'9 .797DOJ Expiration Date: <br /> — <br /> J/ <br /> Data: Q/ Contractor. <br /> 1Q <br /> Title-, n"�� <br /> Slgnatulx: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declandlOns: (CHECK ONE) <br /> _I have and will maintain a cartiflwts of consent to seltdnsure for workers'cwnpansatlon,as provided for <br /> by Section 3700 of the tabor Code.for the performance of the work for which this pemtk is Issued. <br /> have and will maintain workers'Compensation Insurance,as required <br /> by S Section <br /> 300 of the Lranceabor�e <br /> for the performance of the work for which this permit Is Issued. My red <br /> carrier and policy numbers are: <br /> Carrier.�t`r �^�c Polley Number: &7/J— 72A <br /> I certify that in the performance of the work for which this permit is issued,l 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 1 <br /> should become subject to the workers'compensalion Provisions of Section 3700 of the labor Code,I shall <br /> forthwith comply with those provisions, Q <br /> Expiration Date: Signature: 4a ,y <br /> Printed Nsms: 'r1 �n <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CSVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN D ADDIITIONTO ION HE OF OF COMP ODEON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDEF <br /> AUTHORIZATION FOR OTt IER THAN C-67 SIGNING PERMIT APPLICATION <br /> 1 i�_ - x/40 lslgnsture ofC47 licensed authorized rep a onfativO, <br /> hereby sutmurixs(pdrd name <br /> to sign this San Jcgquln County Wgil Penult Application on my behalf. I understand this atlth0fIX91On Ia valid for <br /> one(1)year and;*limited to the work plan dated on tha hard paga of this application. <br /> 8.2"2 r NI <br /> sun io.ef cum <br /> d12=4 <br />