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ZCC 19 ' CuCi <br />San aq.uintCour)ty-Env,Jronmon toI <br />JOB ADDRESS: - 'i 76LGs�f <br />eidth Services, Unit IV Well Permit App <br />F. 2"a <br />cat on �suopivmant <br />Ll <br />ECLARATION <br />I hereby ef`irm thst 1 t,m 1 C-ansed under the provsiors of Chapter 9 (cdrr�me.10ing with Section lox) of Division <br />3 of the B�slress and professions Code and my!'cerse Is in fuil force and effect. <br />u a?r19D cf _ Exp'ratlon Date. <br />License <br />Date: L1 ��of� Contractor V r LtI� LI r i <br />Signature. <br />PrintsO name. <br />I WORKERS' COMPENSATION DECLARATION <br />i <br />I hereby affirm under penalty of ped ury one of t'^.e fovowing declarations; (CHECK ALL THAT APPLY) <br />i 1 ha.,e 5nd will malntaln a certifice!e of consent to se:f-Insure foryy�orkers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the »��rR'For which Ma permit is issued. <br />_.,11'heve an.- wl l rneintaln workers' compenss;lcr irs;r<nce, as req,.;ired by Section $700 of the :.ebur Code,; -! <br />for tho perforrnence of the work for which this per , it Is Issued. fVy workors' compt:nsetlon insurance <br />' rarrler and policy numbers ere; <br />Carrier _ ,rbc �.�� Policy Number: �.7/.J:...`i <br />I certify that in the performance of the work for whlcr this permit is issued, I al -all not employ any parson in <br />any manner so as to become subject to the worse -s' compensation, lays of Celifornle, anal ogres .hat If I <br />should become sul;160 to the workers' corrFensal'cn prov!slons of Seotlon 3700 of tha LSbcr Cade, I shall <br />forthwith comply w!th those provWons. <br />nate:_12 �9dtdn Sltanaturo: <br />Printod Name., 41l7L-xf y C kg& 4 <br />WARNING: FAILURE TOO ErU RE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL, AND SHALL SUBJECT <br />l AN EMPLOYER TO CRIMINAL PENALT{ES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS <br />(S10C,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, ANO DAMAGES A9 <br />PROVIDED FORA SE0710N 3706 OF T "' L.A.SOR CODE, ; <br />I / (C-0711eensed authorized represontative), hereby <br />suthodze, <br />se:.�laaFtt�tt.S�n...loa.au n County Well PermitApPllcatlon on my behalf, i understand this authoftation Is valid for <br />one (1) year end Is limited to the work plan dated on the front pogo of this npp1199110, <br />15 17.2000 / MI <br />12/19/2000 TUE 12:37 <br />6_ "' nclrl/ET/3T <br />IT:1/R] NCS 671U 1 01002 <br />P- <br />