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FROM. _West Hazmat <br /> FAX No. .: 191663BB613 Feb. 04 2002 03: 12PM P1 A <br /> *112/04/42 .X(IN 13:42 FAX 1 9A.M.A.1 04-30 SECOR SACrt_AiCNTO ldlctn2 <br /> TILE COPY <br /> San Joaquin County Environmental Health Services.unit IV Well Permit Application Supplement <br /> Jig ADDRESS:` Jell W.F Nr Sr. 5Twru v CA, PERMIT SR#: <br /> LICENSED,CONTRACTORS DECLARATION LCD <br /> I hereby afflrrn that I rim lir_crised under the provisions of rhapter 9 (commencing with Section 7000)of Division <br /> 3 of the business and Prufesslons Code and-my license is-in full force and effect. <br /> License#:��y `l �rj _ Erpiration Datd:- n 1- 3 '- n <br /> Data. 02- -0 OZ Contractor: <br /> signature' Title �f✓a �hv�tiii�— <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> i <br /> I he affirm under penalty of perjury anrt of the following declarations, (CHECK Al.I _FHAT APPI.,Y) <br /> i have and will maintain:a cortiricate:of consent to self-Insure tot workers'compensation,as provided for ay <br /> /S Ilion 3700 of the Labor Code,for the riarforrnance of the work for wFlieli tfsis permit is issued. <br /> 1 have and will maintain work(,rs'compensation insurance,as required by Section 3700 of the Labor Lode, <br /> for the perforrmirw 3 of trio work for wtuctt this perrnit Is issued, My wnrkprs' corn pen,Orion insi.Irance <br /> carrier anis folic nrtmhoo; aro <br /> Gar Riji ro►�-o fir' PolicyNunliber•: _Z.�7 hl 93V6?Z7y .1 _ ;I <br /> I certify that in the performance of the work for which this permit is issuod, I shall not employ any person in <br /> Tiny muttriet so aS to become subject to the workers'compensation laws of California, and agree that if I ' <br /> should 138(.011M subject to the workers'compensation provisions of lection 3700 0 -Gabor Code. I shell <br /> forthwith comply with those provism n, <br /> Date: bZ'O`Jf-6 Signature: <br /> Printed Name: <br /> WARNING:FAILURE`f0 5ECURE WORKERS'COMPENSATION COVERAGE IS UNLAwrUL,AND SHALL SUSJECT <br /> AN EMPLOYER To CRIMINAL PENALTIES AND CIVIL FINES UP TO CANE HUNDRED THOUSAND DOLLARS <br /> (S1 00,000,),IN ADDITION TO THE COST OF COMPFNSATION,INTCRGST,ATTORNCY'S f CGS,AND DAMAGES AS <br /> I PROVIDED FOR IN SECTION 3706 OF THF 1 AROR CODE. <br /> (C-57 0consed v athorized reprecentative),hereby <br /> i <br /> to Sion this San Joaq,Uln Caiinty Wall Permit A0pllratinn nn my behalf, I untlerstand this authorization 15 valid for- <br /> one <br /> orone(1)year And is limited to the work plan dated on the front page of this appllcation. <br /> 5-77-201101 Nil <br /> i <br /> i, <br /> i <br />