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7 .e <br />Nov 25 03 04311P Horizon Env. .Ino 91G 939 2172 p.2 <br />-XI oZepar�tnnen <br />A) <br />San Joaquin Counter Environmental Health Y WBIIPermit Applicatfan Supplement <br />LIC N� ONTRACTORS. DELI ARAUON (LCD) <br />F hereby affirm that f am ficenserl under the provisions of Chi4U0 9Ic0mrMe=J119 with Section 7Cpp),of Giv n <br />3af-the-3ns,Ii-cndProfessions Code and my kense is in full'orce and effect. <br />License -Expiration-Date: 1 1-31)T /o 7 <br />i Date: 1 / / ccnlractcr, G_ <br />Age— <br />Signature: Title:/�7yie�+� <br />Printed name: 44 <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty cf perjury one of the following declarations: (CHECK ONE) <br />I � t.fira <br />I have and will maintain a certe of consa7l to self -insure forur <br />wkers' compensation, as provided for <br />by Section 3700 of the Labor Code, for the perforrnase-of�x a A-brwh-h -#is*errraitis i35tred <br />f�I have and will maintain workers' compensation insurancc, as repuirsj..Uy. Section 3700 of the Labor Code, <br />'or the pelform3nce-of t?TevvnTk-forwhichthis permit is issued. My workers' ccmpensatior insurance <br />carrier and policy numbers are' <br />Carrier: _ is S/7-? Policy Number: el— <br />I certiry that in th± per`ormance of the work for which this permit i6 issuca, I shall nit employ any persun in <br />any manrer so as to become sutiect to the workers' Compensationlaw&of California, and aSree that if I <br />-Shvutd becamesubjectlothe workers' compensation provisions of Section 37CO of the Labor Code. I shall <br />forthwith comply w'th those provisions. <br />Date: //�� Signature: 4a!2d:40V:1— <br />A. { <br />Printed Name: eI/J� <br />16kRNtNG:f-4iLVRETOSECIJnWORKERS- COMPENSATION COVERAGE IS UNLAWFUL. oNn SMALL- SUBJECT <br />AN @MPLOYER TO CRIMINAL PPMALTIES AND CMF, FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OFr.WVE tSA.TION,iNTFAEST,-AxTOR4EY3fEE Af D DtgVAQES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br />AUTHORIZATION FOR �AN C-67 SIGNING PERMIT APPLICATION <br />ofC-57 licensed authorized repreaontativel, <br />h"by authorize (print <br />to viga fhPs sac. Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />IMI <br />r - d OOZC 13C83SUI dH WdOS:9 EOOZ SZ AON <br />