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11/09/2004 11:28 FAX 7149396759 <br />11/09/2804 10: 14 9168610430 <br />(VEST HAZMAT <br />SECDR <br />San <br />-1aa4uin C°unty>inv'ironmenta) Health Se Ices, <br />Unit <br />j0B ADDREss:� <br />U 002 <br />PAGE 02/02 <br />1V Well Permit Application Supplement <br />PERMIT $R#:lz <br />LICENSED CONTRACTORS DECLAP.A110N (L�) <br />hereby <br />-,�fin-n that 1 am licensed under the provisions of ischapter 9 in full forceo nd effect. ding mth Section 7000) of Division <br />3 of the Business and Pr Code and my license 5 3 f O <br />1619 15 LA Explmtlon Date: <br />License: f� It�t r U <br />O GpntractOf: /� <br />Date:rim " l U �L k1lA <br />Title: <br />Sign <br />` Printed <br />aro C-rL/t7f <br />COMPFNSATION DECLARATION <br />f er'ury one of tine following declarotions: <br />(CI.IPCK ALL THAT APPLY) <br />1 hereby affirm under penalty o p I ensatlon, as provided for by <br />I hav and will maintain a certificate of consent to self -insure for workers' temp <br />S ion 3700 ef.the Lobor Coda, for the performance of the work for whi4h this perrn`t iSissued the tabor Code, <br />have and will maintain workers' compensation insurance, as required ke Section encs 0 <br />for the performance of the work for which this permit is issued. My workers' compen6atlon insurance <br />carrier and policy numbers are:. <br />I 1 K l FD of Policy Number: <br />Cagier: 6 ` person In <br />I certify that in the pe <br />rformance of the work for which this permit is issued. I shall not employ any p <br />ancl <br />any manner so as to become subject to the wo sars, p ocomvisionsiof Section on laws of 3Tl�4rn a.e Labor Code, I shell <br />should become swith those provisions. <br />forthwith comply <br />IN <br />Dat®: bye Signature <br />6, r <br />Printed Name: �- - <br />�It�IG: FAILURE TO SECURE WORKL'RS' CO VPE NES UP TO O NHUNDRE',DTHOUSAND DOLLARSGE IS UNLAWFUL, AND SHALL WARN <br />Ala EMPLOYERiO CRIMINAL PENALTIES AND CI <br />$10p,d00.), IN AApITlON TO TH>< COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES' AND DAMAGES <br />PROVIDED FOR 1K SECTION 3708 OF THE LAEAR CODE- <br />Utensod authorized reprceentative), her4bY <br />this authot'ization is valid for <br />I understand <br />to sign this San joaa <br />uin county Wel[ Permit Applt�hon on my beralf. <br />one (1) year and Is limited tv the work plan dated on the front page of this application. <br />