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San 40;4gain CounSY EhvIrbn <br /> n+ery t HeamDemftent unit IV Well Permit Apprcatian Suppl�rnen! i <br /> JOB ADDRESS: ` <br /> PERMIT' $R#. <br /> LICeNSLD CONTRACTORS DECL•A ATICN C� <br /> hereby arlrrn that 1 am kensed under r*pMvist My of Ch <br /> 3 of the Busfm=ana 7000)eptet 9, metpft VAth Soft of Dfy on <br /> ssntis Cade and my Ilre It Riff furca and <br /> mrd effect <br /> l ` <br /> 3.ices+ss z(9/ � ante; D.. " <br /> Data: Z _ ..,,.._ <br />- 1 rt1q; IL <br /> Prinied name- W'I rr T --- <br /> �1 :� <br /> .WOWCERM COMPED 7101Y DEMARA710N <br /> T hereby affimt UnderPenalty of perry one of ft 1:oiloyvirtg d0clat8tiort5: (CHECK ONE) ► <br /> -- .I Have w4 wile miwntWn a cerwaWs of consent in selu <br /> tmtu'e fbr vrorkaus camPft=wan.,aa p+'avideb for <br /> by Sectkn 3M of the]Labor C'^{ar rhe pee marts&&She work*w which this permit ei rued. <br /> . I have&W wil m8fnIain w' wk �s'cum - <br /> far the pensBGan irtsurzutce,es required by Sedeorr 3700�r the]..odor Code,at the wa*icor werie'�I this permit Is iozued. My world'aompens8dai insumnee <br /> wrrier ted porn n bem ire: <br /> C +'r'ler:�- �_ P0110Y Number. <br /> I cgrt y fltst in ine p"MMw ya Of the W*k fbr rvhidv this MMit IS(sued, I�+8ii not employ sny person In <br /> any manner w as to became 5ilbjeO to the workers'��jcn i'dm of iia, �j th8t.fi l <br /> shouldthw bewrrte sub#ec;to i p WM*er''¢srnpen-tMG0n Mvsims Of SK*n 3700 of&a Uhar Cade,I shelf <br /> �+K#l'1�arr�ty welh tiZu�e�, <br /> Data. <br /> l�rintad N8rtrt4: ' <br /> WARNING:FAILURE TO Si~cUR]E VIOMMS'6'i71!MMAMN COMA091g UIRA FUL,AM MA"SUBJECy � <br /> AN WAPLOYER TO MUMMAL PWWAL IE3 AND CAM Fwo up To con H[lMORIED-MOMM VOLLAPS <br /> I:I � <br /> �1ta>:ADMED iN err To Tw C=Of COWMSA'WK MM;U ,A'r'MNUM F ANE,a ►cgs AS <br /> �a IN SE2M Df:�LAMM <br /> AUT140RV-ATION FOR.PyEr THAN C-67 SIGNINr. PERlir WAPPMATION' <br /> argnwm WC-VaW6mUsd vap, <br /> 1 ►a�trrorPxs int ��.,�� �+�k�,�r::: .o�--_ � <br /> ��gn��Jasqu,rn roeaAy Won 1�8 AppefsaA�on my bM1dC A and this tllorr ie valid iyar - <br /> ot,e(i}year and to UmMd to do work Pisa damd on 9M front pqp oi.lRta apWICMon. <br /> IRS 1 iMl! <br /> i <br /> . r <br /> I <br />