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FROM West Hazmat FAX NO. 19166388613 May. 19 2000 11:08AM P4 <br /> 05/19/2000 11:36 20946iT!18 AGE STOCKTON .../ PAGE 05 <br /> X'' X41,+: .. <br /> J09 AbbRES$ Z 13 - �OO� PRMIT� SR* <br /> C� aa.. ,'�., <br /> `)�:K+r...r.-�y�' �'�'YT?i"�Y�A' .��r � _ �- ��ilW'bl ki,a•:. ��:C.'�''� ,.....t' r, �._�+� - <br /> LICENSED CONTRACTORS DECLARATION (L} <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Divielom <br /> 3 of the BUsinaas anndgProfession&Code) and my license is in full force and effect <br /> License A Ss 1 / 7 S _ Expiration Date: &--3/- 26a <br /> Date: Contractor, <br /> Signature; , Title: ,�yc. (Gxi� /�eB arAia ✓a <br /> Printed am47 9: «rA <br /> WORKI=RS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a cerilli ate 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 /> fl have 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 pefmil is issued, My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:��S Policy Number: _V8 <br /> 1 certify that in the performance of the work for which this permit is Issued, I shall not employ any person In <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that it I <br /> should become eubjedt to the workers' compensation provisions of Section 37UO of the Labor Code, I shall <br /> forthwith comply with those provisions- ,, Q <br /> Date: 6S- /`J-op Signature; <br /> Printed Name: ./�/ 'urrr+m /-�lAi <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100;p D0.),IN ADDITION TO THE CCST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE- <br /> (C-57 license holder), hereby <br /> authorize ___,C/f lIG/�" of —6 40AC tA . rrR a �A��, _._(consvltin9),to sign this San <br /> Joaquln County Well Permit Application an my behalf. I understand this authorization Is valid for one(1)year - <br /> and 16 limited to the work plan dated on the front page of this application. <br />