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08/28/2001 12:07 707568600- CLEAR HEART DRILITNG PAGE 02/06 <br /> ,LI.. kl. 1.m rAA 141 £1475 PES ENVIRONIUNTAL Q002 <br /> 6B/27/2001 13:58 209466343J FIFTH FLOCIR PAGE 02 <br /> I <br /> I <br /> l <br /> San Joaquin County kEnvtrorlmertal Health Services, Unit IV'Wed Permit Application Supplement <br /> JOE ADDRESS: 6 [' PMfT ISa#: <br /> J <br /> LICENSED CONTRACTORS DEC -ARAT�ON (LCD) <br /> I hereby affirrri that I am licensed under the provisions of Chapter n (ccrnmenclpq with Section 7000) of Divl$lon <br /> 3 of the Business and Prc+fessions Code and my license is in full force and effect. <br /> .�1 I <br /> License#:. __ !�a� � Pxpira#ian Date: <br /> [Date: a 7/L� Contractor:..ammm- � <br /> Signature: Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DFj`?_,RATIr ON <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHr;CK ALL THAT APPLY) <br /> have and wili maintain a certificate of consent to self-insure for workers'Trnpensatlon, as provided for by <br /> /Suction 3700 of the tabor Code,for the performance of the wor;for which this permit Is Issued, <br /> ✓ I have and will maintain workers'compensation insurance, as required by Lection 3700 of the Labor Code, <br /> for the performance of the work for which this permit iS Issued. fviy workers'compensation insurance <br /> carrier and policy numbers ere: !I <br /> n / <br /> Carrior: (, V Polloy Nurnt�cr: (.:'e-lr00 o <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner sa as to become subject to the workers'corn pan sation laws of,Celifomia, and agree that if <br /> should become subject to the workers'compensation provisions of Settionl3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> T/Z7/41 <br /> bate: Signature: <br /> Printed Name: <br /> WARNING. FAILURE TO SECURZ VVQRKERS'COMPENSATION COlr1 tRfkGE IS U LAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP 7'O ONEHUNDIRE-0 THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPEN$AT'ION,INT'EFE:5T,lATTORN5Y'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODS. i <br /> I <br /> I. _(G-57 Ilcansed nut horized representative),hereby <br /> authorize a ✓ j _ _ <br /> to sign this San Joaquin County Well Permit Appllcalien on my behalf. I understand this awtherization invalid for <br /> one(1)year and is limited to the work plan dated on the front page of this, application. <br /> 5-17.2000 I AAI <br /> I <br /> I <br /> I <br />