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08/20/03 TUE 11:48 FAX 510 6 4141 GE031ATRIX OAKLAND 121 016 <br /> San Joaquin County Rnvlronmontal Wealth pepartmtent Unit IV ell Per^+7Apant <br /> PERMIT S 2-0 <br /> JOB ADDRESS'- 02 1., 2 t- <br /> LICENSED CONTRACTORS DECLARMATIOI herettY affirm that I am IiceMSad under the Prmislcenfhn tulptrbr(ceo nd effeotDivision <br /> 3 of the Business and professions Code and y <br /> Expiration Data' <br /> Licensd 0: r-, <br /> GonirgOor: lie <br /> Oats: <br /> r <br /> 'title. <br /> Slgnaturo: <br /> r <br /> Printed Want»: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby sffirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will rnlllntain a certificate Of Consent to Self•insure tot workerS'cornpensatin n,ea proyi0ed for <br /> by Section 3700 of the Labor Code,tar the performance of the work for which This permit is Issued. <br /> r which this permit is Issued. My workers'compensation insurance <br /> I have end will maintain workers' <br /> �mpensa6orl insurance, a6 required by$eotlorl 8700 Of the Labor Code. <br /> 41- for the performance of the wo <br /> carrier and policy numbers are: <br /> Policy Number: <br /> Carrier: � an arson in <br /> s Perm <br /> I certify that in th s to become subj�t t0 the workeperformarwrs'sh compensation k ws of California,ait 115 issued,I shall not nd agree ih2tl+of t1le work for 6hal1 <br /> any manner so a <br /> should become subject to the workers'compenastfon provisions of Section 370iU of the Labor Code, <br /> forthwith comply with those pravialons. <br /> Data, 5lgnaturs: <br /> r <br /> printed Name: <br /> AWfUL,AND <br /> WARNING:FAILURE TO SECURE WORKRS' CIVIL FINES UP TO ALL SURiECT <br /> PENSATION COVERAGE <br /> HUNDRED �Hp gO�AS <br /> AN etMPLarER TO CRIMINAL.PENALTIES <br /> (51Do,000.1. <br /> IN ADDITION CTO ION 37E COST Q TtOFlC►DR COMPENSATION, <br /> IN1EReST,ATTORNEY'S � <br /> pROv1oED F <br /> C0126- <br /> AUIHGRIZATION FOR OTH THAN C-57 SIGNING PERMIT APPLICATION <br /> i m*fC.57 licensed authorised representative), <br /> I, <br /> hereby authorize(printaama) <br /> to sign this man Joaquin county Well Permit Application on my Oohelf. 1 understand this awlhorisetion Lr.valid far <br /> one(1)year and is urnitod to the work plan dated on the front Pug of this application. <br /> 9.29-021 MI <br /> aKvlKVo xJ3JVK03D TrT4 CEO OTS %Vd TZ 90coo 7J <br /> 317a EO/9Z/94 <br /> •d OOaE 19r-213Sd"1 did WHOtr ;G C00-a 9z t)rilj <br />