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�J <br /> PAGE 03 <br /> 02/86/2007 14:52 2094683433 , <br /> E7-Q) <br /> I <br /> San Joaquin Cautrty <br /> Enuiranmsntal Health De artment Unit N Well Permtt Application Supplernerrt <br /> JOB ADDRESS: <br /> PERMIT SR#:. <br /> LICENSED CONTRACT'hRS DECLARATION LGD <br /> i <br /> g rpn mencing vial Section 7000) of DMWon <br /> t tzarebY atfim that I 8M tlaenssQ under the prwtstor% of Ctts¢teS' { <br /> 3 of the Business and Professions Code and my lice se Is In futl farce and W� <br /> " , C n Date: <br /> ad2 11 n� <br /> Date: C <br /> Title' r1_i , <br /> Slgnalwre: <br /> Printed name: - I <br /> WORKERS' COMP TION DECLARA'n4N <br /> i u one of the fot ng declarations: {CHECK UNE} <br /> I h6a'3Dy 8ftlrrn unser penalty at peS] rY <br /> to of consent t seNnsure fcrworkcerS' cornpensatron, as provided for <br /> I have and will maintain a cepa of the work for whfdr this petmlt is issued. <br /> by Section 37 DO of tt* Labor Cade,for the perfo�nertrer <br /> I� i have and will ntaintain Mrorlcers' 0=pe-nsabon i{rsurame, as re <br /> Ruired by Session 3700 of the ►.abor Carle, <br /> fnr the perkxrnance <br /> of the work far which this pe{mit is issued. My workers oomPeRsati°n insurans7B <br /> carrier and poticy numbers are: iO�1A3S SC)3 <br /> Carrier: GIS - �G`" Policy NumbQr <br /> I certifyr that in tris performarce orf 010 work for Vch this permit is issued, I shall not employ any Persson n <br /> any manner SC as m tJCCenne subleet to the wo 'compensation laws of Catlfornta. and agree that if I <br /> provtslor of Section 3700 of the tabor Code, 1 shaft <br /> should become Subjed to the workers'cornpen <br /> forthwith comply Mftttl tt Ose provisws. / ) <br /> signetur�e: <br /> Fxpirat3an _ _ �--1 <br /> Date: <br /> Printed Name: <br /> WARXINQ:FAILURE MSECURE WOPJ(EM, GONPEN SATIOW COVERAGE tS U� AMD SHALL SUBJECT <br /> OUS <br /> AN EMPLOYE <br /> H A D7Tt l'lQ TO tFIE COST 0�iI�pEIL FI�IJ�REST,ATTORNEYS EES OW HUNDRED ANO DAMAGES AS <br /> i (5100,00 L I I <br /> pity® FOR Ill sECTION 37%OP THE LABOR CO E. <br /> AUTHORIZAT10 R_OTHER THAN C-57 SIGNING pERMIT APPLICATION <br /> i <br /> Lisig"aWrg of GST t1yQnSod autiaortrad mP' ntatvm? <br /> hwvby as>tt+o*UW(Pri�nwm rstand this au#xKtzattan 13 valid for <br /> to sign this San Joaquin County Waa PwtMt Appllcatlon an rrry behalf. I unds <br /> one(1)year and is[Imibad t*the work pian dWpd on ttr "M Pa°of this a0lcation- <br /> 3-19. 3 00 <br /> I <br />