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FROM West Hazmat FAX NO. 19166388613 Oct. 23 2001 10:11AM P1 <br /> 123/2901 a8:54 20946 40 <br /> 08 AGE TOCK70N <br /> r il�+'f PAGE 02 <br /> I:ij1F I,� i <br /> �a FILE COPY <br /> �. ___-_ _ <br /> am Joaquin County Envirchrnental Haalth Services, Unit 1V ylI permit Application SupPlarnert�' <br /> JOE ADDRESS: , PERMIT SRY>t <br /> Iq <br /> LICENSED CONTRACTORS DECLARATION <br /> l 1 hereby affirm that I am ilcansed under the provisions of Chapter 9(cammencing with Section 7000)or oivision <br /> IdI, , 3 of the lousiness and Professions Code and my license is in hill force and effect. <br /> sY 7 5 <br /> Expiration pate: <br /> 1)ate: /0-Z-3-0/ <br /> _ Contractor.��►/a+3% 1Y�«n r— ���c r . rL <br /> Signatu <br /> Title: a>C✓v AJ-I'L -7'Ar✓'t3 a�� <br /> q Primped name a e+SFr s o v41�WORKERS, & <br /> COMPENSATION DECLARATION <br /> hay 3tt1rm Under penalty Of perjury one of the following declar7tiions: (CHECK ALL THAT APPLY) <br /> d ' <br /> I h6m and wtli maintain a ceikcat"Of consent to self-insure for workars'cumpenaatlon, as pnwided for by <br /> q 3e�tion 3700 of the Leber Code,for the perrcxmanre of th,e Work for wi tich this permit is issued. <br /> I have and will maintain workars'compensatlon in,Auranca. as required by Section 3700 of the Labor Cad", <br /> it <br /> for the perfor'nwrice of the work for which thix permit is issued. My workers'comp"msatlon insurance <br /> j, tamer and numbers are: <br /> t; lar: frb" POIIcyNurnlber: zZ,&Irb✓61027y I <br /> certify that In the per rurmance of the work for which this permit is iSsued, ( shall not employ arty person in <br /> N arty manner$a as to beourne subjrrt to the workers'compensation Icews of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Codo, I shall <br /> forthwith comply with those provisions. <br /> �. �Oats, /b- 2J-o/ ._..__ <br /> M. _ Signatup�� <br /> C <br /> Printed Name_ ics},q-nro <br /> 11, WARNNG:FAILURE TO SECURE WORKERSI COM PENSAriON COVERAGE IS UNILAWFUL,AND SHALL SUBJECT <br /> AN 411PLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$ UP TO ONE HUNDRED THOUSAND DOLLARS <br /> f�1Q0,000.i,IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY`S FEES,AND DAMAGES As <br /> I PWMDED FOR W SECTION 8704 OF THE LABOR CODE. <br /> IC57 IYcensed authorraod reprosamtathrel.hereby <br /> �� y,�dtdirariza . f._.� /YD✓. 6b LhJJ �1Z <br /> I <br /> '' i�l,.'to sign this S"'n Joaquin County Well POI Application on my behalf. I undtfstand this aWhorbtatlon Is v <br /> acid for <br /> one(I)year and Is limited to the work pian dated on the front page of this bppitcation, <br /> "6.1720001 MI <br />