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04/26/2006 16:39 209-579-2225 MMESTO ATC PACE 02 <br /> San Joaquin County Environmental Health Deperbnant UnE N Well Pernift ApplicAlon Suppi Moist <br /> JOB ADDRESS: 3305 O&r ZAN4E r t�, +ERMIT SRO:� <br /> LICENSED CONTRACTORS DECLARATION (LCDI <br /> I hereby afllrm that 1 am licensed under the provisions of Chapter 0(commencing with Sedloo 7000)of Division <br /> 3 or Me Business and Prohssions code and my license Is in full force and infect. <br /> fi*1r*Son Date: <br /> Dow: 2 tr� Cantrector, �.+t....yt- l <br /> Title:_ _. ice h�.�._ i`'•. <br /> Printed <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of Wury ons of the following dederatiw": (CHECK ONE) <br /> I halm and will maintain a cortiticala of consent to telMnsurs for workers'comoonsation,as provided for <br /> by Section 3700 of ft tabor Code,for the peAbirmence of the work for which this permit Is Issued. <br /> �I haw and will maintain workers'componse0on Insuranos.as njgL*od by Section 3700 of the Labor Cade. <br /> for the performance of the worts for which this permit is issued. My workers'eompensadon insurance <br /> arrim and policy riumbam we: <br /> Carrier: - S is �-�-� Policy Wu rAw, <br /> I cartiy that in the performer"of the work for which this permit is Issued, I shat)not employ any person In <br /> any manner so so to become subject to the workers'Coanpensatlon laws of CatHCmie.and agree that If I <br /> should became subject to the workers'compensation provisions of Section 3700 of the labor Code,I Mall <br /> fOrlttMAlh comply with a provisions. <br /> E�Iratkm Dale- '�- / b(0 Blpneture.�r .--• r--� - <br /> Pik, Name: <br /> WAAW010:FAILURE TO SECURE WORKEM'COMPENSATION C*VeRAGE Ice UNLAWFUL.AND&HALL SUBJECT <br /> AN EMPLOYER TO CRRIINAL PERALTIES AND CML FINES UP TO ON6 HUNDRED THOUSAND DOLLARS <br /> 49/60.0ft),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORN"FEES.AND DAIAA062 As <br /> PROVIDED FOR IN SECTION 970E OF THE LABOR COOK. <br /> LITHORIZAOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> stpral,tra dC�T IkrnrsA�sutlro►ked npr+sssntMMl, <br /> l 4 atlace(pnnt name) J . b r AT <br /> to elpn this Scan Joaquin County Well Peanu ApplksHon opt my behalf. I mWerstand this suthodstdon Is valid for <br /> am(1)year and It limned to tfla work Plan dated on the front pope of this appileirden. <br /> 11•2W2-/Mil <br /> EtED 29-02-001 <br /> [R2N4 <br /> z 'd 6zt►�-899 [OE5l 2UIlit-jQ ISa d2a =50 90 92 .rdd <br />