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.1810 <br />06/16/2004 14:01 <br />JO <br />9168610430 <br />San Joaquin County Environ <br />SECOR <br />PAGE 02/03' <br />IVWell P r i plication Supplement <br />l <br />JOS ADDRESS: L59© 5�� �" l.� fi��r PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />y L'CEN�ED C NP RA.CTQ D�EC;�ARAMN � , <br />herb affirm that I am icense under t e provisions o ap er 9 commencing w ion 7000) of Divis on <br />3 of t1i7 Busines and Professions Code ag myV license i 1n full force and effect. <br />hereby afTirm that I am licensed under the prbvsions of hapten 9 (commencing with Section 7000) of Division <br />Licen � the �u2ii f�a: Vrofesslons Code and my li to a inALbf nee and eff <br />x it do ale. <br />Llce e <br />D on c r. —C GaYC n D <br />Date: o t ctor. 0< <br />Signature: Q��Uv <br />Signature: Title: <br />Pr nt Pniii�tl'n <br />��db14R�ii®N CMN <br />I here byrt ghLWRi W1`U 40r#�I"118: ("9dI4 WLTWAr1 AWP1LY) <br />_I M$Nlle"Lafflgo' <br />€atO�i�°sii�r4� °'r1preAlilio'is <br />yectio8o e° oY ire 'performance oo e wor�C dor w�°Sch `hissued. <br />1 have and will maintain workers' compensation irsuranoe, as required by Section 3700 of the Labor Code, <br />— I avef���f}�fR�k�k`dPtflf�6Sar4c�R�f?��d@�ktR��u�@.ri{@f�c�7Ce, <br />for theril9oryfrtbmttSkai®i which this permit is issued. My workers' compensation insurgnc <br />c 3rrier and policy rr r `� p L <br />Carrier: ��--// +�, C� Polley Number. +-t 0 <br />Ca rier: Policy Number: <br />_ ce y a to a performance o e wo or which this permit is issue sMall not employ any person in <br />hogI ertif � etre t €i I� �41��?"S�Iigi "g' XPi 8f fl' it��JN <br />'j�sRn n <br />y , �,Ci c�j s v�o�'e�s°c8rri� sone �g o�Ca`li%rnlaa� grd thsa�if I <br />a m �, he en anon a n <br />ould 5'ec m s ct o e ers compens on p vi of Section e Labor Code, I sh II <br />f rtb"�t�t ttyose ovisature: <br />Date,: : /0-01-�� • _p31igb9dtRiaete: tJ LUJ <br />WARNING: FAILURE <br />AN EMPLOYER TO CRIM O SF����S' COMPENSATION COVERAGE i3 UNLAWFUL, AND SHALL SUBJECT <br />WAR I 0 go. ?(( �� MPENSATIQN INTEREST ATTORNEY'S FEES, AND DAMAGES AS <br />N COVEkAGE IS UNLAWFUL, AND SHALL SUBJECT <br />P Y I IN ND ClV NE HUNDRED THOUSAND DOLLARS <br />( 1 0, 0.),l H T F PENSATIO [PtlEST, ATTORNEY'S FEES, AND DAMAGES A <br />PROV licensed authorized representative), hereby <br />authorize <br />I'toMgnthissarijogeitil- Well Permit App"ealilen on <br />if��getlhe44(�4fil�,{14�t�&(�YrB)idlb <br />autho i�1ar `_ami ts_I�m1aRlaadateddn t►+aa of tis a>6e►tos2;orky ��Z� <br />to sig thif-SM11h0uin County Well Permit <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />5-17-2000 / MI <br />£OOIIn suTTTTdG PJs.»P0011 OHttL£LOL XVJ tZ:VT �00Z/S1/60 <br />