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MAY 02 2003 8: 513AM HP LASERJET 3200 p. 3 <br /> 1(fly-DI-03 03:04pn Fro"RDWR AND CALIr t- <br /> 91fi 636 9906 T-091 a.oa'Ileas F-9I}9 <br /> San Joaquin County EAYtronmelltat Health Department Unit IV Well P®rmlt Appticafti}on SvpIP#errant <br /> PERMIT SR#; �v <br /> JOB ADDRESS-. t 1 ' � N `� <br /> LICENSED CONTRACTORS DECLAFZATION LC <br /> I hereby affirm that I am licensed Code and my licenses In fullforceforce and affect.with Section 7ppt7}of i7ivisfvn <br /> 3 of the Business and Professions <br /> t icenta#: Expiration Date: <br /> Date: � Contract r. <br /> Title; <br /> Signature: / <br /> printed name" �-✓ <br /> WORKERS' COMPENSATION©ECLARAYION <br /> I hereby affirm under penalty of perjury one of the fnilowing declarations: (CHECK ONE) <br /> for <br /> l h section 3700 of he Labor Code,for the performacate of consent to nce of the work orrwwh ch this permit Is W&U00 ed For <br /> by <br /> I have and will maintain workers' compensation inisurance,as requlred by Section 3700 of the Labor Cade, <br /> I <br /> the performance of the work for which this permit is issued. My workers' Compensalion insurance <br /> carrier and policy numbers are: <br /> Policy Number: <br /> Carrier: <br /> n the perFafmance of the work for which this permit is issued, I shall not employ®ny person in <br /> I certify that i <br /> any manner n as to become subject to the workers'compensation laws of Californ and agree that if I <br /> should become subject 10 the workers`eompensstian provisions of Section 3700 th abor Code, I shall <br /> forthwith comply with those proviaiOnll, <br /> I]ate• Signature: <br /> Printed Name; ! <br /> WARNING:I AILURETtS SECURE WORE AND CIVIL SATION NE5 UP TO ONE HUNDRED Tj40USANDOLLARS <br /> GE 15 UNLAWFUL,ANO SHALL U�JECT <br /> AN EMPLOYER TO CRIMINAL PENR <br /> PROV(01 000.),FOR Ao SECTION 37o8COFST EFICOMPABOR CODE- <br /> AUTHORIZATIONSATION,INTEREST,ATTORNEY'S FEES,ANfa RAMAGES AS <br /> OED <br /> FOR OT ER THAN C-67 SIGNING PERMIT APPLICATION <br /> r (signature oic-s7 lleanead authorized representative), <br /> hereby authorizo(print name) <br /> to Alen this San Joaquin County Well Permit Application an MVV gena . I understand this autharization ia•,►alid for <br /> one(1)year and is limited to the work plan dated on the front Page of this appricQ110n. <br /> 0.20-=l u1 <br />