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10-31-1995 10 56PM FROM <br />J • ii VV:G4 IAA 1 Sib bbi U4,50. SECuR-sAcRAMENTO <br />olaff-241 /‘ <br />San Joaquin County EnvIronmentkrgilth Sagices, Unit IV Well Permit Application Supplement <br />PERMIT SR*: 610722---47 <br />LICENSED CONTRACTORS DECLARATION (LcD) <br />1 hereby affirm that am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is in full force and ette.dt. <br />License #: J0 g .g(c S Expiration Date: 1 31 0 (-4 <br />Date: 4.-2,(4 -OQ. Contractor: r)V e0 n nrkein01) <br />wallower:- <br />Printed name: 0,-\\ I-15C <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL 'THAT APPLY) <br />have and WU maintain a certificate of consent to self-insure tor workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit IS isSued. <br /> Policy Number: 1.5a6r)OS / <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, arid agree that if <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, shall <br />forthwith comply with those provisions_ <br />Date: 4/-04 - (-) Signature: <br />Printed Name: viV <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL SUBJECT AN EMPLOYER -ro CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED 'THOUSAND DOLLARS <br />($'100.000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S PEES, AND DAMAGES A$ <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />v S•c_4-1 (signature ofC-57 Ficensed authorized representative), <br />hereby authorize (print name)7141,-/.••• ).4.) c - <br />to slgri this San Joaquin County Well pe,rpilt Application an 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 />5-17-2000 / MI <br />P. <br />100u2 <br />JOB ADDRESS: " S cA,`"teizt coC <br />f-orot g4),, <br />Title: nt _LrYL_O. <br />have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers' compensation insurance <br />carrier and pc )icy qumbers <br />cif <br />Carrier: