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DEC 19 00 1Z 3� taEST:Gc -ElfL.-iti�EGE-53E3-��2-�•?7? �G <br /> San Joaquin County Envlronmantal Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS; PERMIT SFZ <br /> • Qom/ �, Gib .�lr. . OOZY g.� . .� <br /> LICENSED CON RACTCRS DECLARATION CLCD) <br /> I h@;EOy affirrn that I am licensed under the prov'sionc of Chapter 9 (commencIng wim Section 70DO)of Division <br /> 3 of the Buslress and professions Code and my I'cense Is in full force and effect, <br /> `Icanst,�: Ex;;ratlort Data. <br /> ' Date: AakQ Contractor, V- k/ zt'�i;,a * i <br /> S1nattJre: Title: •�A,,/--� - <br /> larin`so name. Jta& /!A/ir.�,�_- ,. <br /> WORKERS` COMPENSATION DECLARATION <br /> 1 hereby aft`lrm under perelty of per ury ane of yr^s following decfaretlons; (CHECK ALL THAT.APPLY) <br /> a 1 have end will malntalrt a cert'.ficete of consent to se:f•tinsure for workers' compensation, as provided for by <br /> section 3700 of the Labor Code, for the perforrnance of Ine work for which thls permit is issued. <br /> �I.7sve eno wlil r:einta'.n workers' compensation Insurance, a$ regvired by Section 3700 of the -abor Code,;- -,a:; <br /> for tho p.-rforrnencs of the work for which INS pert-A Is Issued. M.y workors' compensatlon insurance <br /> csrrler and policy rtumbers ere: <br /> Carrier, _ policy Numb or! 7/.j5 3 3 f-1- 94 <br /> I csrtify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to beoorme,aubjectto the workers'compensaticr.lays', of Colifornle, and eptee that If I <br /> should becoMe su171001 to the warkars' provlsions of Se..tlon 3700 of the Lsber Code, I shall <br /> fort. wlih aotnply with t`tose provlslans. <br /> Date ? �-��n --- Sfenatura. �• <br /> Printediurnec <br /> r WARNING, FAILURE TO SECURE WORKERS'COMPENSATION COVEftAOE I3 UNLAWFUL,AND SMALL aL1 gcT <br /> AN EMPt.OYSR To CRIMINAL PENALT1l"s AND CIVIL PINES UP TO ONE HLINDRED THOUSAND DOLLARS <br /> PROYIOEP F RDD 5 CTff O 37 COFS7 FIA�bR COpFION, INTEREST,ATYd1:it�tEY'S FEES,AND CAMAGES A8 <br /> (C-a7 lloenaisd suthorl=ad representative). hereby <br /> w <br /> �IJttlOrtZ� <br /> to sign this San Joaquin County Wall Permit Appileatlan on my behalf, 1 and*ratan¢thla outhorlistion Is valid for <br /> one(1)year and Is firnited to the work pian dated an the frolit Ata¢of this appllceitlen. <br /> _5.1720001NINA — <br /> eC�:'n.: r,=�- E.ErEB37c2Z I;S�::i 2aCt•/�T/Qt <br /> 12/19/2000 TUE 12:37 [Tt/A] NO 671t53 0002 <br />