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FROM : West Hazmat FAX NO. 19166388613 Sep. 07 2001 03:17PM 1`1 <br /> '09/07/:001. 14:45 2094C,71�17 AGE �3TdCVTnN <br /> PAGE 03 <br /> . . .-_.. ,,.,.� Irc.akiun lerrtan <br /> San Jc�a city Coy....._.......__ hp <br /> ,qty Fnrrirtsrtmenial Health 5tertrice6,Unit IV Well A©+rriit A ZZ <br /> PER 5R#: <br /> JOB ADDRESS. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licen3ed under the provisions of Chapter 9(cornfnencing with Section'7000)of Uivir. an <br /> ,,ti. 3 of the Susiness anis peafessioits Codo anti my license is it,full torr r:ynri erffOct. <br /> tl`7� ^7 'IF <br /> Fxpir�tion Darr. <br /> L <br /> k License'#. _ <br /> 2)rt,e 4C.r,JL Cop.,- <br /> b�- 01 Contractor. `f: <br /> Date: D 9� - ._.. -- <br /> ---- 7W, <br /> WORKERS' COMPENSATION DECi!ARA ION <br /> I hereby afftrrn uy,cief penalty ai perjury rine of the fgtiuwing der_iarations: (CHECK AI.I. THAT APPLY) <br /> (flava was will maintain a ceitteat*of aannent to self-insure ter workrrrs' oo mperrtiation. as provided for by <br /> $ 4"ion 3700 of the i_abtar Gj)dc, for the performances ut the work for which 0 rie permit is issuod. <br /> 71have and will muintoin workers'Compensatioo insurarice, n:3 required by Section 3700 of the Laoor Code, <br /> for the prlrforrnance of the work far-which thin permit is issued. My wArknrs compensation insurartud <br /> carrier and policy ajuirabers era: <br /> rix ��'-' ,...,Policy Nurnitor- ? 1rJ ,✓6 P 7`(�—.. <br /> r <br /> s/certify that In the performance of the work for wtlir:h this permit is isar.arsd, I shall riot er oiny rany pe3r3on in <br /> any manner so ds bs beroma stjbjOct to the workers'cornpe3nsatanrt IRws of CnllfrarniH, at id agice that if I <br /> should become subject to tho workars corrrperisation Iar'mvr.ions of Section 3100 of the Labor Code, I hail <br /> foahwith comply with thot;(4 provisions. <br /> f <br /> (� b 7 U t rtatttie: _.. .._. . ._. <br /> Data- Sl( - ... <br /> printed Nartrlli'l .r( ? <br /> WARNING=FAILURE 70 SECURE:WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL-SUMIECT <br /> AN EMPt.-AYFR TO MMINAL PCNALrIEs AND CIVIL.FAMES UP TO ONE HUNDRED 7'llnUSANU fiOLI ARS <br /> J4100,00OR N 0.) �TI N 7 BF [� <br /> N To THE COST <br /> F Comp CQA- Carl,INTEREST,A-M)RNEY'S FEES,AND D"AGES AS <br /> PTtUVI <br /> - (C-57 licensed authorized repTosentsstive),tteral�y <br /> �1'................--- _.. .._.._ --'L <br /> i <br /> authaMzet//� _ _T .._..... .. __ . <br /> to sign this Sar+.loaquln County Well permit Applltat)on on itry behalf. I understand this autilorixatlon Is valid for <br /> t *no(1)year and Is ilmited to thu work plan dated an thel front rMW of this apPlicatlon. <br /> _-----�— <br />