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06/ 14/ 2007 13 : 26 $30675600 STRATUS NO CALIF f-'Alat n�rui <br /> II <br /> WA <br /> $an Joaquin County En>rlronmenfzrl Haakh Peparprtent Unil N Well Pefmlt ApPllcation ,54pploment <br /> Slt 9 <br /> JOB ADDRESSa Anj ar� b 74U� N Ef 90(A a 5j, PEF�'AIT SRPI:� s7/ s Qz <br /> � 5/ S9L <br /> LICENSED WNTRACTORS D@CLARATION (LC I) <br /> I hereby affirm that I :gym licensed underthe provisions of Chapter 5 (conurm6ncing with Sectior• 7000) of PIVISioh <br /> 3 of the Bus9ness and Professions Code and my license is in full forca and educt, <br /> I <br /> License #: 33( ( F.Viiration bate: <br /> data: Contractor: rA W <br /> Tdb; <br /> Slgnatu <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby afiirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and Will maintain <br /> a certificate of consent t* selfw1olure for wal(t m, compensation, as provided for <br /> by Section 3700 of the Labs' Code, for the performance of the work for which this permd is issued. <br /> Move <br /> and will maintain workers' compensation in6Uranoa, as required by flection 3700 of the Labor Cade, <br /> r the parPonnanca of the work for which this permit is issued. My worcers' compensation Insurance <br /> carrier and policy numbers are: r�h1 <br /> Carrier C �'�if'YI -�i � y Policy Number: y <br /> 1 certify that in the performance of the work for which this permit is issued, I shall nal employ any person in <br /> any manner so as to become subject to the worker' ocmpansaGon laws of cal'domis, and agree that if I <br /> should become subject to the workerm' compensation provisions of SecHcn 3700 of the Labor Code, 1 m;Mall <br /> forthwith comply w h thane provisions, <br /> expiration Data: � Signature <br /> Printed Name: 1 <br /> WARNING: FAIt,URE TO SPCUW WOMRs' COMPENSATION COVERAGE IS UNLAWFUL, AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE IJUNDNED THOUSAND DOLLARS <br /> 0,10pl 17EDl IN FOR IN YI N TO HE OF THE COMPABOR NSATION, INTEREST, ATTORNEYS PEFAk AND DAMAGVS AS <br /> CODL <br /> AUTzopRIZATION FOR OTHER TITAN O-'57 SIGNING PERMIT APPLICATION <br /> (umgriwWro ofG67licensed authortrad mprosu"12 ira)y <br /> humpy authoNxa (print na 16 1 i n <br /> n is va0d for <br /> sign I n this Ssn Joaquin Cuunty Well Permit Appllr3aan on my behulF I undwrstan4 this xutharizaliu <br /> enu (1) year and is limited to the work Plan Ogled nn the front Pxge of tthls lipplicadon. <br /> 1.2&02 i MI <br /> 6t1P 39{12r(JDI <br /> 622104 <br />