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JUL 20 2004 12: 21PMLASERJET 3200 P. 1 <br /> ° PAGE 03163 <br /> 07120!2004 11:55 2994671ad ACE 5 OCKTOtJ <br /> V <br /> San Joaquin County Envifonmantal Health Department U it Well Permit APptiG�iof►su�� nR <br /> JOB ADDRESS: ea' PERMIT SR#, 66////�� OQ <br /> LICENSED CONTRACTORS DECL RATION U-0 <br /> I hereby affirm that I am licensed under the provisions of Chapter 9((Qmrn eCg with Sa6tlun 7000)of Division <br /> an <br /> 3 of the Business and Professions Cade d my license Is in full`o >anO <br /> t. <br /> License "'r� ExpWatlon Date: <br /> Date: f D Ca c W: <br /> �r' r <br /> SiOnaturo: Title t <br /> Printed name: E <br /> WORKERS'CDMPENSATIaN DE LARATION <br /> I hereby affirm Under penalty of perjury one of the following declarabi ns- (CHECK ONE) <br /> )/I have and MR maintain a certificate of consent to selWnsufe for workers'compensatioA,as prcMded far <br /> by Section 3700 of the Labor Code,for the performance of the ark for whk:h this permit is issued. <br /> Y", have and will maintain workers'Compensation insurance,as re ulred by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. y wortcers'Carnpensetian insurance <br /> carrier and policy numbers ane: <br /> Policy Numb r. c/ <br /> I certify that In the perfornmanCe of the work for whldt this permit s Isstled. I shall not eryiplay any person In <br /> any manner so as to become subject.to the workers'compensai on laws of Cahfamis,and agree that T I <br /> ahoutd become subject to the workers'Compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiratlan Date:g �Signatta^e: - <br /> s r <br /> Printed Name- <br /> WARNING:-FAILURE <br /> ame:WARNING:-FAILURE TO 9ECURE WORKERS'COMPEWBATION COVEY AGE 15 UNLAWFUL,AND SMALLSUBJECT <br /> AN ompLOYER M CRINOMAL PENALTIES AND CML FINES UP TO ON HUNDRED THOUBANI]130t.LARS. <br /> 0100,0004,IN ADDITMN TO THE COST OF COMPENSATION,INTERMS t,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVNM FOR IN SECTION 3706 OF 711E LABOR COOS. <br /> AUTHORIZATION FOR OT C ING PERMIT APPLICATION <br /> 1, rg TC.67 Ilamed authorized mpresenta11ve4 <br /> ir <br /> hereby suit afts(prem name <br /> to sign this Saul Joaquin County Wad Permit ApplicsMon on ray behalf. 1 undersUrid this autlwrizadon Is valid for <br /> r <br /> we(1)year and Is limited to the work plan dated on the front Rage of this apPACS63n. <br /> &31-D211MI ..�. <br /> EM x402-01 <br /> 9x30=02 <br />