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.00T-27-2009 17:38 ARCADIS BRIGHTON MI 810 229 8837 P.04i06 <br /> OCT-26-2009 17:45 ,`RCRDIS SRI(3HT0N MI 810 9 8837 P.62/02 <br /> San Joaquin County Environmental Hallilth DepartMont Unit IAV Well Permit Application Supplemental <br /> JOig ADDRESS: PE RMIT SRO <br /> LICENSED CONTRACTORS DECLARATION 19D) <br /> I hereby affirm that I aim licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and eA'er1. <br /> License M Q o 4- E xp Date; _�'=s.)-L �Q L <br /> Date: 10- 12(4p. Oq Contractor. V 1 Qd IQ)( <br /> Signature: GUtx% Title: I Ce 11 (Qn ee <br /> Print Name: <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> Zi have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued_ <br /> I have and will maintain workers'compensation insurance.as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation Insurance carrier and policy numbers are: <br /> Carrier; -1 Policy Number: L l0 <br /> I certify that in the performance of the work for which this permit is issued. I shall not employ any <br /> person in any manner so as to become subject to the workers'compensal an law of Cafifernia, and <br /> agree that If 1 should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shell forthwith comply with those provisions. <br /> Exp. Date• QA- Signature: <br /> Print Name: lYaU L- <br /> WARNING:FAURE TO SaURE Vvomiii GOM'aNSATION COVERAGE IS UNLAWFUL,AND SHALL SUHJ&>±T AN EMPLOYER TO <br /> COUNNAL PENALTIliD AND CMI.FINES uP To 11o0,11110,IN ADDITION TO THE COST OF COMPENSATION,lWrEVIM, <br /> ATTOANEY•5 MRS.AMD bAMADa AS PROVO Dr p Poll IN SECTION 37H GF THE L wOlt CODE. <br /> AUT RI N FO OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> 1' u (signature of 0.57 licensed Authorized ropmsXentativs), <br /> hereby autho (print name) a QL,F'S :3)i rWO9 .to <br /> sign this Sen Joaquin county Wolf Permit Appilavion on my behalf r understand this outhorl>tation Is vend <br /> for one year and Is limited to the W*#*plan dated on the front page of this application. <br /> trt91Q?1MI <br /> ii „troy <br /> TOTAL P.02 <br />