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JAWrIM0 Z 0 0 2 <br />12/09/2003 TUE 13:21 FAX <br />7„ <br />� <br />nvironmen, t Waaltt� Sere• e�, Unit IV Well Permit-ApR <br />.}lication S� <br />San oaquin County 3 <br />P5-RMIT SES#: <br />SpB ADDRESS. <br />LICENSED CONTRACTORS DECLARATION (—Lc[)) <br />hereby att�rm that I aM IiGCn58d under the dprovi lions offs in full force and effect. <br />witr7 SeC<<on 7000) of piv,sron <br />I <br />"s of the business grid profosslons Code an Y — <br />0cc) <br />Expiration Date.License #:n �// ontrar. <br />cio�L <br />�f <br />, Title: <br />Signature: <br />Printed name' �.! - ' ' - —j <br />WORKIrRS' CQItA?ENSATION DGLARAi14Pd <br />L THAT APPLY) <br />1 hereby af;irm under penalty of perjury one of -the following declarations: <br />CHECK F,L <br />cnsation, as provided for b`,' <br />{ have and wili maintain a certificate of ccr, rfCrmanceto` the work for0. k`Nhich this Permit n issued- <br />- Section 3700 of the Labor Code, for the <br />ermit is issued. My workers r-0MpQnsatiQn insurance <br />have and wi!I maintain workers' compensation insurance, as required by Sectia'z 3700 of the Labor Code. <br />tnr the perforrnanc� of the work for which this p <br />carrier and policy numbers are: �1 <br />Policy Number: 1 <br />Carrier: P y y erson In <br />_ I certify that it the performance of the work for which this permit is i ,51jed, I shalS not em to an P <br />f I <br />pm ensation provisions of SedtiOn 3700 of the Labor Code. I shall <br />i ce manner so as to become subj oto tnepworkers' compensation laws of California, and agree that I <br />should become sut�ject to the Yorke <br />forthwith ornp y wlth those provisions- r <br />Signature' _ <br />Printed Name- <br />$ AN <br />AN eMP1_OD G1VIL FINES UP TO ONE HUNDRED Q FEES, DAMAGES AS <br />WARNING: FAILURE TO SECURE WORMERS COCr1PENSATION COVERAGE IS UNWFUL, AND SHALL SUBJG T <br />Y>=R TO CRIMINAL PENAL r <br />(5700,DDa•}, }hl ADDITION TO TNI= CAST OF CQNIPENSATION, INTEREST, ATTORNEY'S <br />PROVIDED FOR IN SECTION $706 OF -rHF- LABOR GOOF'• <br />tC.57 licensed authorized represcntativpj. h Y <br />au�horizE <br />uin County Wcll Permit plication on mY behalf. l understand this authoci dtion is slid for <br />to sign this San _4oaa lication- —• <br />year and is limited to the Work plan dated on the front age of this ap -- —J' <br />one t1 ) _� - <br />w0b '� WCt '- = 2 1 GGR 1.-VEi-0 1 <br />