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t <br />AUG 22 2003 11:43AM HP LASERJET 3200 <br />08/22/2003 11:38 2095224227 GLULLY.21UPL <br />San Joaquin Cpun vironmehral Health Services, Unit IV WO' PermitAPP,Ileetion Supplement <br />JOB ADDRESS: "•-16 /t/ PeRMFT - SR*: coe .359 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />Signature: () Title: <br />Printed name: 11 /4-1 /61c1-(-- <br />\ <br />/ <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm under penalty of per)ury one of the following declarations. (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-insure for worters' 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 />I have and will maintain workers' compensation insurance, as requirsd by Section 3700 of the Labor Code, <br />. for the performance of the worK for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: G <br />17cerlIfy that in the performance of The work for which this permit is issued, I shall not employ any person in <br />any m anner so ea to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of inc Labor Code, I shall <br />3 • <br />forthwith comply with those provisions <br />Signature: <br />. <br />R6t-r d <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES I115 TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION 10 THE COST OF COMPENSATION, INTEREST. ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />1. P ct-- ii() a.). d_9-,t- (C-57 licensed authorized represenbatIve), hereby <br />A uthorl2a r) W-n'S...0 Lift0 k))i raj 74e--ri-) pl ./Ps, <br />s. 11__ <br />to align this San Joaquin County Well Permit App cation on my behalf. I understand this authorization is valid for <br />one (11year and le limited to the work plan dated an the front page of this application. <br />I <br />I hereby affirm that I 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 effect. <br />License #: (...0 510 40 (1 Expiration Date: <br />Dateig f 2-2-1C2 Contractor:rcrfq -tqk_ <br />lag • • <br />Policy Number: 44 /AD 0 02. / 7 <br />Date: <br />Printed Name: <br />hOdd lAldLE ,E 6661-SE-et <br />E 'cl