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FEB-06-2001 11:32 FP^M PRECISION SAMPLING TO 19169283341 P.02 <br /> 02/02/2W1 ®9:27 2894b63433 FIFTH FLOOR <br /> PAGE 85 <br /> i <br /> Satz Joaquin County EnvironrtnervW fleatth Services,Unit IV Well Pensit J4pplicatton Supplmeni <br /> i .tt3B ADDRESS: N W 6W-+Ja12 41�- Zy PERMiiT SRllit: <br /> LICENSED CONTRACtORS DECLARATION &CID <br /> I Hereby atkm that i am lied under Vio provisions of Chapter 9(0ornmeric:ng with Section?'NM)of Y}iv s n <br /> 3-of the eustness and Profs sons Code and my tieanse is in fidt forte and affect, <br /> ExpDate: d► ' 3l '/.�UZ <br /> Date~ Contractor. � Gl Sl�!-� Gjp<M�l ti1(� L• <br /> Prnrted t L 1�/X VJ Ill <br /> WOWERW COi', ENSAMON DECLARATION <br /> 1 <br /> I hL4eby affirm under pefWty of perjcrry ane of the f lto-rring d ations: (CHECK ALL THAT APPLY) <br /> I hme and WiN mmintain a cerlfta%of content to-saf-Inoue for mmxkers'campenaation.as provided for by <br /> Sedan 3-M Qf th8 Labor Code,hoc the perfamk-mce of the work for vohk: �this pemOt Is 6mied. <br /> V/1 neve and wrtl rnalntain vmrkers'compensation insurance.as requked by Sectim-3700 of the LO MW COde. <br /> for the performance of the wrack for Widal►this permit Is lss► . My.trackers'compermtion insurwKe <br /> carrier and pcirry numbem are: <br /> Policy Kwnber_ l 2 1 <br /> ✓ I cc3myr Mat in the perfocrriarrce of the mark far witch this permit is Issued.1 shell not emplary any/person is <br /> `any manner so as to become subject to the workers'cQmpersa ion laws of California and agree that it I <br /> dvUld b0corna S&ject to the wore owWMwwm provisions of Secfian 37nO of tho Labor Code,1 shag <br /> fbifi tAth comply wM ttaasa provisio+Ys. ?' <br /> Date: 1 Sutura: 9 <br /> printad Hamel <br /> WARNNG:FAILURE TO SECt11W RS'COMPENSAT KM COVERAGE IS UNLAWFUL,AND SMALL SUMMECT <br /> AN EMPLOYER TO 0MMILAL PENAL-"ES AID CML FINES UP TO OK WMMD nMMAJO MAARS <br /> ($1 00,00&),M AMITION TO THE CO3T OF COMPEMAMK 1WEPZ6 ',ATFDIi; rS FEES,AND DAMAGES AS <br /> pRoVWED FOR 04 SEC HON 3706 OF TIE LABOR CODE. <br /> cls j N 1 Cd�� ►-b�il�ZU� l'� ,��'. �6�r'I�1 <br /> to atgn Ws Say.laaqutn City V%li Permtt Apptic ation on nr bdndf. I undorstm d thus aulh ftatlon Ls vabd for <br /> one(1)yiKw and Is Ii mild to the work plan daeod on the*"d paW of this NW lcaftw. <br /> 5-17-2M 11i <br /> TnTPI P F1',:) <br />