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10/20/2004 WED 09:44 FAX I AOL 02/0_1 <br /> StC:IiF: <br /> F7H:'I a]l,9EJ tt4:i4� <br /> San Joaquin County nvi o mental Health Department unit IV W Well Permit Application Supplement <br /> PERMIT SM <br /> JOB ADDRESS: " �I <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 3 of thbe©esy affirm s and PTrrfess'le ns Code andMYliven s of Chapter <br /> fiullrforc,aa�e er wit�Se^fon 7000)of Division <br /> -1 0 Fxp' • ion Date: <br /> License#:. 1 ��' <br /> _Contra tor: 7/� 1 - <br /> Date: Title: <br /> Signature: <br /> Printed names <br /> WORK-Rso COMPENSATIa1 DECLARATION <br /> llowing declarations: (CHECK ONE) <br /> I hereby affirm under penalty of perjury one of theto <br /> —by Section ill int enLabortcode, for the performance of the rork forwh ch this permit isissued <br /> for <br /> compensation insurance,as required by Scndlon 3700 of the Labor Code, <br /> I have and will maintat worker-'camp <br /> wo iters compensation insurance <br /> for the performances of the work fcx which this Permit is issued. fv1Y I � <br /> cattier and policy numbe are: <br /> C G _PnllryNumber: "J t <br /> Cartier: lo an Person in <br /> and agree that if I <br /> certify that in the performance of the work for which thLs hermit is issued,I shall not employ y <br /> any manner so as to become subject to the workers cnmpisions of laws of California, <br /> should become subject to the workers'eompensa ion provisions of Sec ion 3700 of the Labor Code,I shall <br /> forthwithtCom lyvi those provisions. <br /> I Signature. �~ <br /> 1'1 r <br /> Cato: ltL 1 O Y <br /> Printed Name:' D Al D SHALL SUBJECT <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL., <br /> AN EMPLOYER <br /> TO ADDITIONIINA L PENALTIES AND THE COST OF COM CIVIL <br /> FIN Nu INTEREST, <br /> ONP U RNEY'S FOES,AND DAMAGES AS <br /> IN <br /> (5100,000.1, <br /> PROVIOEO EOR IN SECTION 37D0 OF THE LABOR CODE' <br /> AIJTHORIZATION FOR OBER THAN C47 SIGNING PERMIT AppLIGT <br /> ION <br /> I � f ��/ t gna are ofC-571' mused utho 'z�� rose^tetiv0) <br /> h <br /> ereby authorize(print namal� . <br /> ign this San Jnaquln County <br /> Well Permit APPlicatlon on mY behalf. I understand this authorization is gild for <br /> (t I year and ILlimited to the work plan datedon the front pagrof this aFlPncatlen-021 M( - -- - <br /> 17�16�"(tUJ FRI 01:20 TTgitiF Nn 5222 I�.i0U2 <br />