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NOU-30-2000 16:29 FRDN:TWININGi BS, INC. 559 268 0740 TO: 094683433 P.002'002 <br /> NOU-30-2000 15:41 EOMATRIX FRESNO <br /> 559 264 7431 P.02i02 <br /> San Joaquin County Environmental Health Services,Unit N well Permit Application Sppp)ement <br /> JO$ADDRESS. B SIE #9 /z t1tc.or C.A , PERMIT SR#:_ <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> 1 hereby affiml that I am licensed under the provisions of Chapter 9 (Commencing with Section T000)of Division <br /> 3 of the business arc Professions Code and my license is in full force and sffea <br /> License#: 1506/-4� Expiration Date- ag a L8 0 1 <br /> Date: 3 D AJ Contractor:_:r-ZJ1A)[AAq A A 9- $ <br /> Signature: Title: D1015/Oa .t"A46-4 <br /> Printed name: AeRAZ I/�K <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I hexa and vnll maintain a certificate of cOrzent to self-insure for workers'compensation,as provided for by <br /> Section 9700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensaBon insurance.as required by Section 3700 of the Labor Gude, <br /> for the performance of the work for which this permit is issued. My workers'Compensation insurance <br /> carrier and policy numbers are: pp <br /> Carrier5M715 r&A)jD Policy Number. <br /> _I car'*that in the performance of the work for which this permit is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Callfomia,and agree that If I <br /> should become Subject to the workers' compensation provisions of Section 37"00 of the Labor Code. I shall <br /> forthwith Comply with those provisions. <br /> per; Signature: <br /> Printed Name: <br /> WARNING;FARAD RE TO SECURE WORKERS'COMPENSATION WVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CROAINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S1 00,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 1, .r/L(. rQZyA�SKI (C-67licensedautheAaedrepresentaWe),hereby <br /> authorize QaLr al /f'r 13aa- i2eoc reix Cem-- n(7" Zhu . <br /> to sign this San Joaquin County Well Permit Application Prl my behalf. I understand this euthorka8on is yarrd fur <br /> one (1)year and Is limited to the work plan dated on the front page of this application. <br /> 5.17-20001 MI <br /> NOV-30-2000 03:3415M TEL)559 264 7431 IDITWINING LABS, INC. PAGE:002 R=100% <br />