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i <br /> 19/19(2001 09: 49 7073745677 WOODWARD DRIL_L1' P/IGE 1 <br /> of?(15/2001 1�_4B E9-5?`J5 h" CIESTU ATC <br /> sxn Ja quin County l rtvirbn A it;erVIc4$, Unit IV'd 01I Permit Application SuPi;1;mar,t <br /> JOS ADbFtE53: f n of PERMIT SR#.-- tJ ( / _ 1 <br /> LICENSED CONTRACTORS DECLARATION (LCO) <br /> I hereby agflm�thrt I am licensed under Ute provlsions.of Chapter 9 (rammencing with Secticrl 7000)of ols, on <br /> 3 of the, Business and Rrofmseirins rode and my license is in fril Marc 1 and effect. <br /> i <br /> License 0. _ - _ ` ..._ _ _Expiration hate: . <br /> Date: t. �.? ,_a` _ Contractor YWOODW14-90 qt <br /> SSignature: ems_ w�� Titils ✓JL�c_&J�7 �rU _l�fkhd+aP.6' T <br /> Prtntad name: — <br /> WORK1--RS' c0MPLNSATI0N DFt'LARATIONi 1r <br /> I hereoy aFitm underpana!ty of perjury one of the following deciaranons; (CHECK ALL THAT APPLY) i.. <br /> I <br /> 1 heVel and will maintain a rert':fitate of consent to seif•;nsure far;gotrkerS'compensecon, as provided for by ' <br /> S Ltioti 3700 of the Labof Code, far the perforinonce of the work for which this permit is issued. <br /> 1 <br /> ' =e and wil: mainta;n workers' eampencation insurance,as req,dired by Section 3700 ofthe Labor Code, I <br /> "re perforrmtnce of the work for which this permit Is 'slued. IAA workers' compersatlo.^ insurance <br /> cur anti pricy numberu are: <br /> Carrier: "ITAT45 FUNO polio Nurnbar: . 7 G? <br /> I aertir✓thak Ir+ tee performance ofl.he work for which this pe:rmIlk is issued, 1 shaft not employ any person in <br /> any manne, so as to ba;co nc suoteCtto Ute workers'crmpensat;rr.taws of Celifomla, and agree that if I <br /> should neccnt.e svt ect to the wo±hers'compivisaten provilsions or Sec;ian 3^704 of the Labor Code, I sha?; <br /> forthwith comply with those provisions. <br /> i <br /> - I <br /> Printed Name: <br /> WARNING FAILURE TO SECWt* WORKER`. COMPENSATION COVCP+%,G= 13 UNLAWFUL,AND SMALL SLIeJEG' <br /> AN EMPLOYER TO CR MINAL PENAL.TIFS.Ahu CIVIL e'NES UP TO CNE HUN DpFo THOUSAND DOLLARS <br /> tSiHo,o00.} IN ACIUiTION CO YWC COST O4, COMPENSATION,INTER,-ST,A:iTEt Rfif;Y'3 Ft;ES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION:1706 OF THE LABC:R CODE, � <br /> t <br /> I <br /> I,__W._ I,,� fl �''_dC'�'. 7"!r✓ ._ y {C Cil ilrsnoad authvrizwd reg rasent0tivob herepy ! <br /> i <br /> to sign NIS San,tpaquin ('nunty'Well Por mli Application on my hohalf. 1 undensfand this authwrisaxtbn to valid to, <br /> i <br /> one(1)year and to II1<1itvK! to trsa «aro plan rJatn.y o.;the want A�*He or".t�lx,apl7'tca43nn. I <br /> 4-17.2000/Mf VA' <br /> r <br />