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FROM West Hazmat FAX NO. 19166388613 - May. 19 2000 11:07AM P1 <br /> 05/19/2000 11:36 2094671'M AGE t3TOCKTON PACE 04 <br /> a, <br /> JOB ADDRESSy �1, PERMIT- <br /> SRO. <br /> aA447t �'.'�..'x-n. .s -�-' `.' �R k'--M;, .'K .ire .. ...a._......:r <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> I 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 licanse is In full force and affect. <br /> License k: SSy(It Expiration /Date: 0/-3/- xoel <br /> Dote: 6"9" °" /1 Contractor, Wes. <br /> Signature: Title: !t' �6 ;2+b dfwC <br /> Printed name: �—. .-- - ---- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby Wrm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have end will maintain a cenificnle 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 /> AI have and will maintain workers' compensation Insurance, as required by Section 9700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation Insurance 1 <br /> carrier and polity numbers are. <br /> Carrier:/ -^S __r Policy Number: <br /> 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> ony msnner so as to become subject to the workers' compensation laws of California, and agree that it I <br /> should become subject to the workers' compensation provisions of Seolion 3700 of the Labor Code, I shell <br /> forthwith comply with those provisions- <br /> Date: D S / ?ro a Signature' ' `� w <br /> Printed Name.WARN , <br /> ING: FAILURE To 5 EC U RE PLOYER TO CRIMINAL PENALOT EVS AND L FINES COMPENSATIONTHOUSANDDSUBJECT <br /> P TO ONE HUNDRED DOLLARS <br /> AN EM <br /> l$100, IDN IONTO rHE COST <br /> T EFI1a MPENSATION, INTEREST,ATTORNEY'$ FEES,AND DAMAGES AS <br /> PROVIDED FOR i <br /> �r ",later A. �N,..�tyzfeiYy�/� � -_,,, /- (� (C-57 license holder), hereby <br /> L b�ze ��,�lF.-�1f!!,_... of _t1..r ,rll�f vlf Cop 4 n (coneultlnp),to sign this San <br /> Joaquin County Well Permit Appll"W on my behalf. 1 undursiand this authorization Is valid for one(1)year <br /> end is limited to the work plan dated on the front page of this application. <br />