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01 / 09 / 2004 14 : 04 2094671 " " 9 AGE STOCKTON PAGE 02/ 02 <br /> JAN 09 21104 11948RM LRSERJET 3200 <br /> p . 2 <br /> San Joaquin County Environmental Hee Department U It IV Well permit Appllcatlon Supple man <br /> JOB ADDRESS: S RMIT SRII;� <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions Of Chapter 8 (commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license Is in full force and eff77a�ct, <br /> License N: Expiration Dale: �j'DLL _ w <br /> Data: 1 Contractor. <br /> signature _ p D.C � iD <br /> --�. . .. <br /> Printed name: _ I�11=c <br /> C1 <br /> WORKERSF COMPENSATION DECLARATION <br /> Ihereby aRirmunder penalty ofpeljuryone ofthe following declarations: (CHECN; ONE) <br /> I haire and will maintain a certificate of consent to 3e1f4nsure for workers' aompensa6on, as providl :d for <br /> by Section 3700 of the Labor Code, fpr the performanoo of the work for which this permit Is issued, <br /> t have and will maintain workers• compensation Insurance, as required by SecOon 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 aro <br /> Carrier; <br /> 11 % Yd�tirn polity Number . <br /> I certify that in the performance of the work Ior which this ermit is issued, I shel l notl not em� <br /> any manner so as to become subject to the workers' comp P y y pa son in <br /> should become subject to the workers• cam ansa0on pensatlpn laws of Calilfamla, and agree that 6I <br /> forthwith Comply with those proWslons• P Wwlsions Of Section 3700 of the Labor Coda, I shall <br /> Date: / a Sfonatura_ <br /> � _ _ <br /> Printed Name; _ � a f t "a.. / ~� <br /> WARNING: FAILURE TO SECURE UyORKERs' COMPENSATION COVERJIGB IS UNLANUL, AND $HALL St IBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO <br /> (;1 EMPLOYER <br /> , IN AD ONE HUNDRED TN <br /> ADDITION TO THE THOUSAND DOLLARS <br /> PROVIDED COST INTEREST* A <br /> EO FOR IN SECTION ST6s OF THE LABOR CDDE. � ATTORNEY's� FEES, AND DAMAO ES A9 <br /> AUTHORIZATION ,FOR 2NEA THAN C47 SIGNING PERMrr APPLICATION <br /> I, 4 .7t a <br /> (si attire afC=67Imaaed outhorkod repress Nauw), <br /> hereby suthorLm (Print nama)� 1 V g p amt L _ J <br /> to sign this Sm Joaquin County Wall Permit Apphcatlon on my behalf, l understand Ihla authOH28tloa la veva Ad rex <br /> one (1) )rear and is HhlltW to The work plan dated an the front page of this application, <br /> 6,29.02 f fdl <br />