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10/04/2004 14:54 205-579-2225 NODESTO ATC PAGE 02 <br /> / ��^ ,,�'d ' <br /> (� - Y <br /> San Joaquin County EnAronmantal Health SerrlaN,Unit IV Wall Permit AppUCatlon Supplement <br /> JOB ADDRESS:-Le to s D. �e«e«A rT r7ec�aas✓ PERMIT SR* 3qa ?Gnt <br /> LICENSED CONTRACTORS DECLARATION (LCD) II <br /> I hereby 9;:sat I am rofess ons Code nd m vision$ of Chapter M fu }Ores antl enacts,with Section 7000)Of Olvisl Ort I <br /> 3 of th <br /> License 9: 7/ OO 7 q Expiration Date: -7 O S� <br /> Data: <br /> D� o r-/ Contractor: <br /> L O D uJ�}"GZ.�� n? f �"� �✓G C°u "` <br /> Signature: <br /> 6�)e y'zo%� Title: <br /> Printed name: L ^� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm urder penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> ! I have and will maintain a csrtiBeate of consent to seff-Inaurs for workers' compensation, as orovltled for by <br /> SeCtlOn 3700 of the Labor Code,for the performance Of the work for which this permit is Issued. <br /> i have and will maintair workers' c0mPsn4atlor Insurance, as required by Sector,3700 of the Labor Cede, <br /> for the performance of Vie work for which tris permit la 'ssued. My workers' compsnsstian insurance <br /> Carrier and policy numbers are: <br /> carrier: S f=rwaC1 Policy Number. <br /> ami <br /> Me performance of the work for which this permit In Issued, I shall not employ any person in <br /> 1 certify that in <br /> any manner so a to become subject to the workers'compensation laws of California, and agree that H I <br /> should become subject to the workers'compensation provisions of BecCon 3700 of the Labor Cede,I shall <br /> forthwith comply with those provlslona. <br /> Date: /o�o Z Signature: <br /> Printed Nems: C172+4 G L InJ O U D <br /> WARNING;FAILURE TO SECURE WORKER'S'COMPENSATION COVERAGE 1$UNLAWFUL,AND SHALL 9UBJIICT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLAR$ <br /> (jjoa,000.�IN ADDIT;QN TO 37 SOf THE LABOR COST Olt <br /> SSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A9 <br /> PROVIDEDFOR IN SECTION <br /> 1. � — (CAT licensed authorized represents"),hereby <br /> euthorizs <br /> oa C_ <br /> to sign this San Joaquin County Well Permit ApplidstlOn on my behalf. I understand this autborlzeNon Is valid for <br /> ane(1)year and in limited to the work plan dated on the front 0490 of this eppaottlan, <br /> 8.17.1000 f MI <br /> ;:00[n xuTTTTu0 puampooM 00£bb L£L0L XVA 9T:91 600Z/£O/TO <br />