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08/03/2004 13:46 2094678 AGE STOCKTON PAGE 01/0 <br /> E C[E�V E DQ <br /> A/rr !rte AUG 0 3 2004 <br /> San Joagiuln County r;WA omnenlal Health Dglig"Ment Unit IV Well Porn,it EALTH <br /> JOB AD0RIE93- D PERMIT E1110: PERMIT/SERV CES <br /> LICENSED CONTRACTORS DECLARAT)ON (ItM <br /> I hereby aftrn that t am licensed under the provisions of Chapter 9(commencing with Section 7000)of Div Sion <br /> 3 of tho ousirmss and PtoftwonS Code anti my licence is in hull farar3 nmd r�ct, <br /> larr'nset�: eg 7 71751,0 Expiration Date: <br /> - <br /> Signature. `�� i it#e. <br /> Printea name.,_ � �owlae T <br /> WORKERT COMPENSATION DECLANA110IN <br /> I hereby affirm under peiiraiy of piaoury ane of the Ibiiow rig deciarntlons: (CHEC'K ONE) <br /> i have and will melftin a cortit-roatrs of 000ftnt to espif»i ure ivr wgrKenu'compensation,res provided 1 Dr <br /> by 8=- fth 3700 of the labor Code,for lire parit)rmance of the work for which this permit is issued. <br /> I have and wlir moinimin wnricars'coimpensation insuraince,as required by Section.3700 of;hu labor G ode, <br /> flat the performance of the work for which this permit Is issued. My workerW immpensabon insurance <br /> carrier and poli <br /> cy <br /> numberss fare: / <br /> CRrrfer; Policy Number: <br /> I certilli'hot in the performance ai the work 1br which this permit is issued,1 shall rout om010y any persni r in . <br /> any rnannpir na as to hLimmo tUG jei t to the workers'compensation Iowa of Cdllfbinia,and agree that if i <br /> 511PIAW b, =Me subject to the workers`companoptibn provic!j4nt of Sr_edlRan 37ua c the labor Code,I n call <br /> fbAftNith C1FP1Y^jth these proweic rTs, <br /> apt°: 3 d slignawrre <br /> Pt'+ir11eSI Nams; . /��dG!i_ <br /> WARNING:FAILURE To i;E0Up u'W*MRS,cpNlPiJNsa7tCanl GQVSIiA=1t t.ItuLAWFLIL,AND SMALL 81JE HOT <br /> AN -MPLOYeR To k:Rm wL PENALTIES AND CIVfi,FINES Up To Ct4A HUNDRED 1'14OLIMMO DOt,I,ARB <br /> i$9QR,Q00.),IN ADDITION TO THE Corr bt;GOWCNSATION,INTERriST,AM>oRN"4!;REES,AND DAMAGES.to <br /> PROVIDEO MR IN-95Cjj0N 27W or-TW LABOR cool* <br /> A H1 R17ATt F&RITHtTHAN 0,167 6IGNING PERMIT APPLICATION <br /> i' {signature=47 licensed AuAhgriWd represooitIC yr , <br /> hrmby Aulfierlrp(prim:narrrrr) <br /> to Sign this son Joaquin Cogra),r Well permit Appilonitan on My behalf, 1 pnder9fhjnd*111;luthorimilon 10 valid#rw. f <br /> orn•(1)Yor and's rirnftd W ON WOrk Plan darted on the froni1 pu9,of tt►EF 40paca"art, <br /> azeia Mrel, <br />