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FROM West Hazmat FAX NO. 19166388613 May. 19 2000 11:07AM P2 <br /> 05/19/2000 11:36 209467,"'18 AGE STOCKTON PAGE 03 <br /> x �� _ PERM17"swR <br /> JOB ADDRESBP C �3 <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7D00 of Division <br /> 3 of the Business and Professions Code) and my license is in full force and effect <br /> License ifa Expiration pate: d/- 3/- 2 f <br /> Date: ( 15`G a Contractor klteF �'yO <br /> Signature: w Title: NaL. Cita�� /?Egp1 /N hi�ar <br /> Printed name: - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penelty of perjury onh of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will malrttain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the pertormsnce of the work for which this permit is issued. <br /> I 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 permit is issued. My workers' compensation insurance <br /> carrier andel policy numbers are: <br /> Carries / tzr'✓Z2�'zrd Policy Number: U/3 SLI�o?775 <br /> 'iC 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 so ss to become subject to the workers' compEnsation law$ of California, end'agree that N I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: zg- -oo Signature: <br /> Printed Name: <br /> • WARNING: FAILURE TO SECURE WORKPR6' COMPENSATION OCvkRAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (3100,0DD), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> r <br /> �t ceiatr�-a - �A'iC'ZI7.t�'I (C-d7 license holder), hbreby <br /> yutnonze__�y�_� 21(11.0 <br /> —of 6F:,C^V<5ACub ieonnultinol,to Sion this San <br /> Joaquin County Well Permit Application on my behalf. I undersand this authorization Is valid for one(1) year <br /> and le limited to the work plan dated on the front page of this application- <br />