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. . 10002 <br /> :17 FAX <br /> �r'�prjlrGgE'• fV!UJ <br /> SECUk • J7� t,rr4►'G I . <br /> .1 x/26/Zit Ll_ NH: =y y1f,N61 ©a.^rf • '.++-"'� <br /> {�boa auin County.Environmental Health Department Unit IV Well fermi[Application Supplement <br /> Det <br /> JOB ADDRESS:_: 3`)-13 S ,(����/� � PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LOD <br /> with Section 7000) of DiV1Sl°n <br /> 3tafrtl eyl7usin that <br /> ss and <br /> Prlicensed <br /> ofessi ns Code andrmy license is in ful force and <br /> 1dr 9 e ffectg. <br /> (-� "EXP at"mn Date: 'tet �= — <br /> License#: <br /> Date: <br /> Contra tor: W 1 <br /> Title: <br /> Signature: -- <br /> Printed name: V <br /> WORKF-RS' COMPENSATI DECLARATION <br /> I hereby affinn under penalty of perjury one of the following declarations: (CHECK ONES <br /> ion <br /> by have <br /> 3700 of he Labor ificate of Code, far the Perfonsent nnan a of tti wself-inqure forork for wh ch this pbtrcnit is i sued�od for <br /> I rave3nd will maintain Workers compensation insurance, tion insurance <br /> as requited by Section 3700 f the Labor Code, <br /> for the Peri <br /> orrnarr8 of the Work for which <br /> permit is Issued. My workers'compensa <br /> carrier an policy numb ] ere: U i <br /> .�"���/ Policy Number: . <br /> Carrier: employ person in <br /> I certify that In the performance of the work too which this pansa Is issued, I shall not California,on laws of and <br /> to any <br /> any manner so as to become subject to the Workers' cn op- . sl of section 37 0 of the LaborrCode,I f hall <br /> should become subject to the workers' compensa ion p <br /> eision <br /> forthwith r%amPlywitn those provisions. <br /> Date: ��Signature`, <br /> Printed Name:' D - — = r <br /> G Is <br /> AN CMPLOYER TO CRIMINAL PENAIORES AND O V L FIN S UP T ONE HUNDRED TtIOUSANID DOLLARS D SHALL <br /> PROV DPS FOR N Igloo Don.).IN gEOT ON 3 E cOP THE LABOR ODEON INTEREST,AT7oRNEY'S FEES,AN° DAMAGES ns <br /> THORIZATION FOR oTH-01 THAN C-57 SIGNING PERMIT APPLICATION <br /> (elgnat+-ofc-57 lieansad authorized rapresentAtiVO), <br /> hereby wuHte+ize(Print mama) �-----fit. <br /> to si0n this san.loaquin Gountywall Permit Application on my behalf, I understand thtg uthorlautlon is valld for <br /> ono jf)year an`I I_limited to the work plan dated on the front page 0(Wig application. <br /> a — <br /> (--- <br /> �iR] Nri 0312 ) 00Z <br /> 1 C-'1 f;/301•:1 Fat nA�3l+ I' <br />