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Sari Joaquin County Enviranment.'al Hearth Service's, Unit IV Well P rmlt Application nr <br />6� T-Fz�� 0032.08' <br />JOB DDRE$$&KL-- C72b �/ _— FERMI SR#: OF, 0 <br />l <br />LICENSED CONTr` A("P'TJR.S DECLARA 10N (0) <br />i herby affirrn that I si,m, iicensad under the provisions of G!'iapier q (ccmme ing with Section 7000) of Div isior <br />a of the EL: iris arc P'Ufessionsc:, de ;,nd TT; kvitr:,.e is iti full force and e ect. <br />f ir:�ncF �• �� � � � � � � _ f=�:�ji; atli}^ �+c.iu: ! � � I �� �- Q '1 <br />Date: <br />Signature: <br />Printed na <br />I ' <br />Tit',e: <br />I <br />srTe: I � <br />WORKER,'-' COMPENSATION DECLARA.VION <br />;�?r8by a`'sr:Ti L-rder per „ity vet perjury one cf C;; frlinrling declarations: (CIJECK ALL THAT APPLY) <br />1F`n oTi(" 1"i !i I?)iai: a ��e^ia;ate of +,ons ant to sei#-inSUre for worKers', corT'pensation, as j?rOVi'.�eG' for L'X <br />Section 2700 Of The Labe.*r Code, for trie pe [-,xmance of the.wo,, for w.hi:h this permit is issu*rd. <br />i <br />I <br />i hove and,rrTa_ini�i-a workers l;ompensYtior surarn��. es requited b� Section 3700 Of the Labor Code, <br />c)r t ie -e:ljo mance for whic'? this permit is ::.,Sued. My wor4rs' compensation Insurance <br />icat":er and puliuy numbers cre: <br />Carrier: ��"4 L.—Pc1FcyNumbef, <br />i –^ <br />I certify that Ir the ance of the work for vvhich this permit is issue, I shall not employ any person it <br />—^ any manner so as G Lec01'tl? S(ihlect to theWO r.@fS don?ae-fsailcn laws of California, and agree that if i <br />should subjrf is the :Mockers' compensation Prov -ion--of lection 3700 0€ the Labor Code, I shall <br />forthwish cornp!y witrrbi those pi c .-sions. i <br />Date: l (Q _ , O, Gi ana`ure <br />Printed Name: - <br />Q— <br />i <br />i WARNING:. FAILURE TO SEOFIRE'WOR KERS' COMFENSATiON COVERAGE IS ONLAWFUL, AND SHALT, SUBJECT <br />AN EMP -'OYER TO CRIMINAL PENALTIES AND CIVIL FINES ISP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,005.�, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTOkNEY'S FEES, AND DAMAGES AS <br />PROMDED FOP rMECTlt?f?, 370fi OF TOE LABOR CODE. <br />hereby' ti•.liorf =(pi k r <br />540 <br />ofC-97 lloensed Wthorized representative), <br />to sig Wall Permit Application an my behalf. tun <br />one (i) year and 15 r'Rtit*d to thtE work plan dated or the frGnt gaga of th <br />5-17-2DG0 i hrii <br />this authorization Is valid for <br />