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JAN. 9.2004 6:07PM TRERDWELL & ROLLO NO.055 P.3 - <br /> 0 • <br /> sari dpaquin County Environmental Health Services, Unit IV Well Permit ApPIItAtlorl eupplsment <br /> JOB ADDRESS; 604 wessc Zvemot4r Sr PERMIT SR#; <br /> 5rtae,,e.T or,►, e,fa qsa o 3 <br /> LICENSED CONTRACTORS DECLARATION (LCb) <br /> I hereby of Irm that I am Iiparsad Under the provisiohs of Chapter a(commencing with Section 7d00)of Divislon <br /> $of tho Business and Professlone Code and my license Is In full force and effect. <br /> Lkenae#: a piratfon Dote: t f 4t�?ere v <br /> Dale;�Z 3 Contract= aai ion Sc �y,� <br /> 8ignewret <br /> Title: <br /> Printed name; <br /> 101 <br /> WORKERS'COMPENSAT10N DECLARATION <br /> I hereby sffirm under penalty of periury one of the rollowing dedarmtions; (CHECK ALL THAT APPLY) <br /> I hexa and will maintain a cergflcals of consent to Ralf-insure for workers'.compensation,as provided for by <br /> SacvOn 3700 of the Labor Code,for the performance of the work for whloh this permit to Ieuad. <br /> .,�I Rove and will maintain worKore'aomperisation IrWanca,or.required by Section 8700 of the Labor Code, <br /> for the performance of the work for whleh thls permit is Issued. My workers'eorllpensatlon Kaurance <br /> carrier andel p7iJ cy numbers ere: <br /> Carrier L Jor �i 4`rJl�4� Policy Number "uQ710-27.33R013 <br /> __w 'l�5ak' 4vv rat ria r vtvc�Cta� iNs p aaCis i�su l sltiaA(wt Qcttpya�any person in <br /> any manner ac all to bevarne subfeor to Me workers'vampahloadefl laws of a0ffdrok, and agree that if 1 <br /> should become suhJect 10 the W,2*crv,cram an60, proW brLs of$CCNoR 37VO of the i.aberCWO, r snap <br /> forthwith comply vAth those provlslons, <br /> Date; lZr I�I3 Signature: <br /> A <br /> Printed Name; <br /> WARNING;FAILURE TO SECURF WORK9AS'COMPENSATION COVERAGE IS UN6AWFUL,AND SHALI.6119dECT <br /> AN EMPLOYER To CRIMINAL PENALTIES ANP CIVIL FINES UP TO ONE HUNDRED THOUSAND 00"(49 <br /> 4700,000. IN Ap131TION TO THE COST OF COMPEN94-noN,INTEREST,ATTORNEY)$ FEEe,AND DAMAGES AS <br /> PROVIDlD FO,R�INySECTION$705 OF YHE LABOR CODE„ <br /> "^� G57licensed autheiitodrepresentative),hereby <br /> aathodre J).w,`e/4 Lj" .,A �v1=), .11 <br /> to sign this San Joaquin County Well PRrmltApplleaflon on my behiif, I understand this sulllorlzstlon Is VRlld for <br /> One(1)year and Is limited to the wofk plan dated on "a front page of this appliceilon, <br /> 00o I I <br />