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Oct 31 07 03;05p Soilprobe Inc 5E 47400 p.1 <br /> 10/31/ZOU7 13:35 FAN 9492210418 1,ANUAM ASSESS CURD cool <br /> ' <br /> Oct 2607 D1;44p Soilprobe lna 555847400 P.14UG3 <br /> yui cu:cVvr ..a.00 rnn yaefLtLU914 111VUrtU eLS.YfSD.�' I;UKY , <br /> I <br /> j <br /> I <br /> San Joaquin County Euvlmrvnantal Health Oepartimnt Unit lV W4 T Permit Appticallon Supplement <br /> JOB ADDRESS: �33E' �f PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I heraW affirm that i em fEcensed under the ptovislons of Chapter 9(commencing torah Sadlon 7000)of E)Wsdan <br /> 3 or the Business and Profeaslons Coda and my Acensels in Tull corse and a <br /> LIcense Ak �.�_�Zd�US E:plratian D9te: <br /> Date: Contractor: <br /> Signature• 7iR1e: �L <br /> Priritad nar►w., <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under oeralty of perjury ate of the folloWng declar-atbhs: (CHECK ONE) <br /> I have and wal maintain a cer0cate of consentlo self-insure for warkers'compensaton,as provided for <br /> ___by Section 3700 of the Labor Croda,for the pertarmance or the work for which thi9 permit Js issued. <br /> 1 have and will mailvWn workers'compelisallon insurance,as required'hy SectJon 3700 of the Labor Code, <br /> foY the performance of the work for Wtdch this permll l9 Lssued. My wo*era'compensation Insurance <br /> carrier and pallcy numbers <br /> Carrier: - t � °'" Polltytaurnber. ! J32'� <br /> 1 certty that in the performance of tile work for which this permit Is Issued,1 shrill not employ any person in <br /> any mariner so as to become subject lo <br /> thra compensation laws orCalitomia,and a�eeihat f<I <br /> should becorTrfa subject to the workerstiovisions of Secfisk►37D0 01 the l.ahor C2rde,I small <br /> forthwith conVty w#h provisions. <br /> Expiration Date:�S4natu <br /> PrttTsd Name- <br /> wArt WIG:FAILURE TD SECURE WORKERSr CCIAI'ENSATION COVERAGE to lUb d-AWFUL,AND SHALL SUWECT <br /> ApIkW PLOYER TO CRUMNAL P ENALT1ES AND CNIL P7Nt:,t' UP TO ONE HUNDRED THOUSAND WLLARe <br /> e , .J,mi DITION TO TIE COST OF COMP01SAIMN,INTEREST,ATT'ORNFY-3 nEt3.AND DAMAGES AS <br /> PRO D FO N Sl=LMON 3700 OF THE LABORCODI. <br /> A TION FOR OTH HAN C-67 SIGNING PERNST APPLICATION <br /> 1, aigrrnture ofC-dTlkensetl¢uthorfzad repressabivo}, <br /> hereby authortzs(print �_ TkQf-'n y ISS$ELL <br /> to sign flits San Joaquin County Well ParmitAppltczWan on sty behal. I understand this QlMorlxation is Yadd ror <br /> one(1 J ywr'and Is W tltad to the worts ptan dated on the front page of this appl4mtfon, <br /> MM ZY-0Z00] <br /> 7 yon <br />