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06/19/2002 12:04 00000000000 i PAGE 02 <br /> I CJL <br /> Risn Je�AgUlh Cburfllir�cnvirYsnmph l Has lJnit!1/Well Permit AppliCstion�npplement <br /> JOB ADDill 14 ERMIT SR#:_ <br /> LICENSED CONTRACTORS DECLARATION <br /> I 1 henetiy t irt7t that I am IiWtrp 2 d undor the prov'"116 of MlaptOr S(00mmencing with 9tcttvn 70Qa}of Division <br /> E 9 of if a�k:she5s ar�d �ro�P.5Si"CvOa 7�t1C?my ilem&b i6 in full fxCa a,4 Weet_( <br /> r7 L R <br /> t3ttR�, -r—•�-�-� --_ <br /> $10miiturat Tutee <br /> Printed name, <br /> WORKERS'COMPGNSATIGN DECLARATION <br /> I haefrOy eftm rider penahy of perjLrY anee Of the fW0W V (CHECK ONES <br /> f eirr erw ill maintain a certificate of uonwt to ttetfdnaure for workers'compeisation,as provitleo for <br /> by Saratipr; 700 of iha Labor Code,for ttlii pafWc 18naa of the work for which this Permit is issued, <br /> nave artr! 11 RlrintalR luofkltYt 7da1l1gtrit�tiQ� insuranCO.�fi r"uited by SoctlaM VW of 2W Labor Cone, <br /> r'for tlls per, mance cr the wpM for wDioh this permit is heave, Myr# orkers'eor,rpen>Rletgn irleurancm <br /> can-*ow !ty num!)ers etre; <br /> lrllrripr:,, tbiicy FiUMbel:_,,,�„�, <br /> I wtify that in the pwfo+mw*e d!the work for wni:h thits pdrrn't is t&a.ed, I shall not 0rrnpioy any person in <br /> tarry mann av,sn.a t,.vcome subject:a the Norkers'compwisaton awe CttllbrH le,ane agree that If <br /> thould trvcptlk!subject to;hA wtXhyrp'GPfnpenoi3tonproyf7 r 3700 of the Labor Code, I <br /> f fon'l Ith n&nplywith those proylsiola. <br /> if <br /> Signature;tm <br /> f Prind Nares: � ,e �. 5 <br /> WARNING t�FAIL R1 15EGUWORKERS'COMPIENSATU3N COVOti�>rCT <br /> 1--� <br /> JVDE IS UNL~UL,AMD SHALL SU <br /> AN EMPLOY " cmul",L PENALT"AND CIM FINES UP TO GNR HUNDRED THOUSMD DOLLARS <br /> 1 (6100300.),IN DITION TO THS COST OF COM13I1NSATION,INTERlsST,ATTORNETS FEES,AND DAMAGES AS <br /> PROVIDED F61k N SECT10M STOS 9 THtr"LAW*CoelE i <br /> A THAN C-87 SIGNING PERMIT APPLICATION <br /> ----- ._(signaturotf"licw ed authorizW rPpmr*sntattve� <br /> ! tlirsby aut f}(print arra) C]C7_lA C,t 1/dM& <br /> to aiAa v a FIKt R4ufin Charity Wett Prrm 1/ypiic�Ition on rn7lsaha I�iendrrrtrnd this authorizatloe Is vatld for <br /> {; one(1)year and I linAted to the work pian cwtod or t%a franc Nage of this applia"on. <br />