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12/29/2004 12:18 FAX 7073744300 podwara milling <br />ot <br />1951 triteMei <br />me* <br />T-656 P01/01 F-567 <br />&>° <br />San Joaquin County Environmontal Health Dopurtmo Linli 1V Well Permit Appiiicatlorerrpr5ipt <br />JOB ADDRESS: <br />es 0 PERMIT $R#: <br />LICENSED CONTRACTORS DEGLARATION (LCD) <br />I hereby affirm fiat I am licensed under the provisions of Chapter 11 (commencing with Section 7000) of Division <br />3 of the Businr, 3 and Prcfessions Code and my licanse is in full force and affect. <br />1 (-)CY1 Expiration Dale: -07 <br />Date: ) 2- • 2C-1 -7-z.4-1.4 Contractor: 1...C.0)01),..Yak-C-3 Cc: I 4••• 6 <br />Sig naturt T tie: <br />Pri nted name: —F--ore- -Pri-Ors^e 1 <br />WORKERS' CCMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following decia 'atIons: (CHECK ONE) <br />I have and will maintain a certificate of consent to self-insure for workers compensation, as provided for <br />by Section 3700 of the Labor Code, for the performance of tr e work for MAW this permit is issued. <br />I have and will maintain workers' compensation Insurance, a required by Section 3700 of the Labor Coda, <br />for the performance of the work for which this permit is issue J. My workers' compo .;ation insurance <br />carrier and policy numbers are: <br />Carrier: ST(=17-N- r-Li-eeD <br />I certify that in the performance of the work for which this pei mit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compeimation laws of California, and agree that if I <br />should become subjeot to the wort-cars' compensation provis ons of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Expiration Date: ioji /2-00 C- Signature: --f------- <br /> <br />rttcd. j <br />WARMING: FAILURE TO SECURF. WORKERS' COMPEN5ATION COVERAGE 18 UNLAWFUL, AND aic.'..LL GU4.iat.:T <br />AN Ei.,PLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000), IN ADDITION To THE COST OF COMPSNGATION, INTIREST, ATTORNEY'S FEES, AND DAMAGES AS <br />r'ROV )ED FCR 114 SECTION 370G OF THE LABOR CODE, <br /> <br />!,ORIZA7;,.;N V-,Ck THAN ,1-57 PERMIT APPLICATION <br />1P-)1\) 1-16N4 (Ill'illiature 01C-67 liCer,5mtl butte. rized representative), <br />hereby authorize (print name) Penv.; <br />to sign this San Joaquin County Well Permit Application on my ruiner. I iinderatane this autharizatier VAlid for <br />rn ( ,) eeer and 15 limited to the work plan deted on the front pa 9 of this application. <br />8.-2s-02 / MI <br />214029432-001 <br />C/22/04 <br />Policy Ni.mber:2 2-(1°L4