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-9002 <br /> 12/26/29F)3 Mid:3S 93 GCW4� ��a"�R � I'AuE u2/els <br /> San Joaqullt Coerrtfy EnvlMrtmarrtal NO3M De parmrent Unft lilt Well Parmit A0011cation SUPPIernent <br /> JOB ADDRE33: 2 14 . Gr 00.w PERMIT .SR#:_ <br /> LICENSED CONTRACTORS DECLARATION (&LCD <br /> I Weby affirm that I am ikwnsed wder the provwjons of"Chwor 9(corrlmemdrta with$action 7000)of Division <br /> 3 of tha business and Pfdg3 a Code and my 5csrtao is in full kwca and ecL <br /> �rm� o�. ")U <br /> M". <br /> ()ata: (o � _.Con r_ I <br /> > d home: s <br /> WORKERS'CO- 16 DECLARATION <br /> I hereby a nrt undor penalty of pledury orw of the following declarations: (CHECK ONE) <br /> f have and will maintain a cardileate of c*n"nl to self4nsufd for workm'compensation.as provided fix <br /> by Section 3700 of the Labor Coda,for the pe*wmw of the work for which thin permit is im.9uad <br /> l have arta!will makfth workers'compamotion inaufanoe.as requked by Section 3700 of UW Labor Cede, <br /> for ft perfmmme of to work for which this permit Is rued. My wedaew compenaaltion Insurance <br /> c�tltar• ne aro: <br /> Paltry Number: <br /> I that in.the perfcm ence of the wok for which this p rmt Is Iss ind,I shall not"ley any person in <br /> any rt MrW s0 as to beonme subject to the World'riga W406on I;ms of Csiifaimla,and ayrra that if 1 <br /> should beowne sul)sot to ft workem'owantas on provisions of n 2,700 of"1abor Code, I shall <br /> fort w ttt comply.w"ihoee provisions. <br /> Date: } _ Slam ure: <br /> Printod Nara: <br /> WAR1t :FAiLUFA TG Sl:Cl1Ri:WQRKMI COPWFMSATION CQIIftArait iS UMLAWFIIL, QmAjA $U13CT <br /> AN 6WWM TO C UML,PENALING AND CML FWS UP TO 01M HMt:IRSD THOILMAND DOLLARS <br /> ($100,00.).W ACCCrM TO THR COST OF COfYtMp Y10N,INTEREST,ATTORt+ Y S FMI AIWO DWAGES As <br /> PROVIDED FOR IN SECrON 3706 of THE LABOR CoDF_ <br /> ORIZATION FOR dMO THAN C-67 SIGNING PERMIT APPE,ICATION <br /> k sWftfsro 0047 licansad autharbod reprssonUtive)r <br /> "by adthotre{,prfrrt nae►a�„1 ��J� �C 0.b ta+• <br /> fa sign this San Joaquin County Well Paatrtit Application on my beharf. I understand this suthorfratlon is valid for <br /> one{t)year and In itrrMW I*thw work Oan dat■d on the frdrd peg*affbin appikaf{on. <br /> tr,2a-02!Np <br /> 12/20/2003 Mil 09:26 ITI/RA NO $2221 (21002 <br />