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09/09/2004 THU 09:50 FAX Z002 <br /> Sep . 2 . 2004 i : 12PM Environmental 33?-5152 Val Wo -4116 P . 2 <br /> San Joaquin County Environmental Health Department Unit IN Well Penmit Application Supplement <br /> JOB ADDRESS: SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm ftt I am licensed undcr the provlslons of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my licenee Is In full force and effect. <br /> License#, Expiration Date: 1 <br /> Date: 014/f/v Y Contractor; JV 0 <br /> Signature. �- Title: <br /> Printed name: T <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pcqury one of the following declarations: (CHECK ONE) <br /> I Have and will maintain n certificate of consent to iseIF-ins ure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> LI-1--nave <br /> ehave 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 insurencc <br /> carrier ago policy numbers are, <br /> Carrier: F ;j policy Number: <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 ao as to become subject to the workers'compensation laws of California, and agree that if I <br /> should became subject to the workers' compensation provisions of Section 3700 of the tabor Code, I shall <br /> forthwith complyth Toseprovisions. <br /> Expiration Data: ID71 104 Signature: ( ' % <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000-),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,ANO DAMAGES AS <br /> PROVIDED FOR IN SECTION 3906 OF THE LABOR CODC. <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> (signature ofC-67 licensed authorized mpreeentative),' <br /> hereby authorize(print name L <br /> to sign this San Joaquin County Woll Permit Application on my boharf- 1 understand this authorization Is valid for <br /> one(1)yone and ig limited to the work pian dated on the front page of this application. <br /> 8-29-02•!MI <br /> ENT?79-07-001 <br /> 9!3112012 <br /> RECEIVED TIME SEP. 9. 11 : 02AM 09/02/2004 T11V 11:56 fTX/RX NO 69367 01002 <br />