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FROM West Hazmat FAX NO. : 1916688613 May. 19 2000 11:08AM P3 <br /> 05/19/2800 11:36 2094671N a AGE STOCKTON PAGE 02 <br /> cos <br /> J 217-0 PERMI <br /> �Q}auJooc� T' SR# =� Z3D <br /> os addaess: _ <br /> a :o �iL i��`:''�•,+. ':�..M J' .�. <br /> LICENSED CONTRACTORS CONTRACTORS DECLARATION (LM <br /> I hereby affirm thet I am licensed under the provisions of Chapter i(commencing with 6ectlon 7DOD of Division <br /> 3 of the Business and Professions Code) and my license la in full force and effect. . <br /> License* SS 7 F�cpiretion pate: O)" 3/ - z 0�1 <br /> p91e; o X-- !S'd Contractor. y <br /> 2+N.A-iu..sZ ( ora <br /> Signature: <br /> Cf <br /> Title: }�°A'. Cltwr '7.ce.rou+t— j�-fTnT.ra <br /> Printed namf;;;::�,c <br /> WORKERS' COMPENSATION DECLARATION <br /> thereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a <br /> Section 3700 of the Labor Codi;, for the performance mance of to the work for whicure for workers'h compensation, <br /> perprovided for by <br /> of mit s ssued. <br /> I have and will maintain workers'compensation insurence, 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 insurance <br /> ' carrier and policy numbers are; <br /> Carrier: _� ! /_- "; --- Policy Number: <br /> I carlify that in the performance of the work for which this permit is iseued, I shall not employ aperson in' <br /> ny <br /> any manner so alto become subject to the workers'com nsalion laws of California, and agraenal i I <br /> should become subject to the workers' compensation provisions 01 Section 3700 of the Labor Code, i $net(..• <br /> forihwhh comply with those provisions, <br /> Date., "c,v __.Signature: - <br /> 14, <br /> Printed Narn <br /> AWARNING: FAILURE 70 SECURE N EMPLOYER TO CRIMINAL PENALTIES AND CIVIL KERS'COFiNf:SIOUf CO ONE, <br /> HUNDRED THOUSAND DOLLARS <br /> OVERAGIF IS UNLAWFUL.AND SHALL U6JEGT <br /> PROVIDED N ADDITION <br /> IN SECTION 3706 OF THE FLABOR NSAIION, INTERES ,ATTORNEY'S FEES,AND DAMAGES A$ - <br /> W(C-571lic0nwe holder),hereby <br /> h of ( �(consstilting),to elan this$an <br /> authorize <br /> Joaquin County Well Prrmll Application on my behalf. 1 understand this authoriwtian Is valid for one(1)year <br /> and is limned to the work plan dated on the front page of this application. <br /> i <br />