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Jun - l8 - 2003 ' 8: 500""" CONDOR EARTH TECHNOLOGIES:s No . 3999 PP. 2/2 <br /> r <br /> Ioaquin County ftnvirar?nsopt21 Hevfth Urvices<,unit aV if Permit Appllcartfon Sutpl�teStan; <br /> JOB ADDRESS: oaa,� ls . � PL <br /> LICENSED <br /> LICENSED CON'T'RACTORS DECLARATION Ca <br /> I hereby a"ft)*t I am licer"d under the Pmyrieigns of CheV*r g(com rlencl"Q with Sectlon 7WO)of Divislon <br /> 3 of the F1usinion anti Rmfesslons Code and my license is in full force and afrea, <br /> tom .._.......,. tt r <br /> License �/ � `Ecpiration lJai�: t { © � <br /> m <br /> 1Date: � Cotma���r:-,._...� .�.IC1''�,�Ll�._,•�'14 �.�..,. � <br /> Slgr�tLurR:^ R.. Title: <br /> Printed name: <br /> f WORKERS'COMPgNZSATjoisl DECLARATION <br /> 1 tareby affirm under penalty of perjury ane of ft fotlowtng daGlSmficws: (CHECK AU THAT APPLY) <br /> I hays Nnd will m0lrtekl 0 tertifiGalle of consent to imif-Inswre for workers' rampensutien,as provided for by <br /> +�f Section 3700 of ti'e La"r Crude.fbr the perrarmanca of 01e work for which thls permit is issued. <br /> !Ireve and Will maintain workam'Corripersotion i:ssuramoe,as <br /> required by e►Ctian 9700 of tRe t,ebar Cade, <br /> Or the pelf manvo of the work for which,this ponmit is issued. My work corrtpensation Insurer. <br /> caalar end pollay rnumbers em, <br /> Policy Number. Ilse Q CA 1 <br /> .. I carVyr that in the prrrom�am*of tha work for which this perrrlit is issued, i shall not employ any perrnr.in <br /> 4nY martn4r 90 am to begome"401 to the 1wCidl enr eornpemse tfbr,laves of California, and agme that V I <br /> should become subject to the Workers cornpensatfon provleloms of Sectlon 3700 of the Mbar Coda. i st+a>r! <br /> farthwt . comply with thosei provisions. <br /> Date: CP 1 jjd S�igrtrture Q.a_, <br /> Printed Name: <br /> WARNING:FAILURE 7*0 SIMURE WORKERS'COMP>r11ISATION cO Q%IS t$NLAWFUL AWG 9FlALt.SIUBJHCT <br /> AN fWPLOY"TO CPJWNAL PENALTIES AND CIVIL FINES UIP TO ONE NVNDPWO THOUSAND DOLLARS <br /> (SlOV100041 IN A001110N To YHE COS"OF COMPENSATION,IN'TERES'T'.ATTORNMY'S SES,AND CIAM MINS As <br /> PROVIDED FOR 1N SECTION 3706 OF THE LAJ9OR CODE. <br /> I►—wit L <br /> licensed authorized repnassnErttva),hereby <br /> asllthar _ <br /> Cali xwR_ r' �_ <br /> W sE1111 this Un County Well Permit Appllcatlon Oh my b0hahrf. r unds!rstautd this nuthcrl"tion Is valid for <br /> one(1)yarand it Cmitrd to the WnfK plan dated on tha froneggs of thks appliaMon <br /> t { <br /> . { <br /> 5-'I7.2'p4a/Mi <br />