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03/19/2003 13:22 714278 ARCADIS • PAGF 02 <br /> 02/26/2083 11:08 21 1, 3 [1R <br /> FSFTH FL7PAGE 03 <br /> aim Joaquin County Environmsn"I Nealth Servlm' <br /> Unit N Wetl P <br /> ermit APpDaa=S,pplampnt: <br /> PERMrr SR#: <br /> JOB ADDRESM <br /> LICENSED CONTRACTORS DECLARATION ULAM <br /> l hereby affirm that t am licensed under the proYR•ions of Chapter 9 <br /> aommermJrt9wlth Section 70001 OfDivislan <br /> 3 at the gusinaas and Professions Coda and my license Is in full Tone ane ems• <br /> I"� <br /> JirationDate: <br /> #:_ <br /> License b� ` r� r <br /> / n <br /> Date: J o <br /> Title: <br /> 9ignsture. <br /> Printed name. <br /> tivgRK'KS, Comp SATION DEC>ARAT)f7N <br /> I hereby affirm under POnalty of perjury one of the TollOwing decierations: (CHECK ALL THAT APPLY) <br /> I have and WM maintain A certificate of consent to self-insure for workers'comp permiio 9 issued.ided for by <br /> Section 3700 of the Labor Code,for the Wormanes of the vrark for which this perm <br /> f the <br /> equired <br /> for the <br /> performance of the work for whichsthis Perm suedation insurance,as e My workers'Compensation insurance ado <br /> carrier andpolicynumbers are; <br /> Carrier: PeRoy Nurxmar: <br /> 1 certify that in the perfarmsncs of the work for which this permh is Issued, I shall not employ any person <br /> m ' <br /> any manner so as to become Subject to the workers'comPensation laws n 370 Omla,and agree Ul <br /> should become subject to the workers'compensation Provisions of ss�tian 370 of the I atror Code, i shell <br /> forthwith eornpiy with thoo@ Provisions. <br /> Data: Signature: <br /> F"Mited Hams: <br /> AN EMPLMR TO MINALURE PENALTIES ANID CIVIL F NES UP 0 ONE HUNDRED'THW9ANDD DOLLARSU C7 <br /> ($1ed,11W IN AWNTION TO THE COST OF COMAENSItTION,INTEREST,AMRNEY'S FEE$,AND DAMA43ES AS <br /> PROVID FOR IN SECTION 3106 OF 7HE LABOR COCGe. <br /> I d1` nnhD 1\1 /lC' ___(-"t9not,ra orC-571iceroed aotltoYasd reNrosentativa), <br /> hereby aalhodae(print nmol <br /> to sign this Son.Ioagain county Well Permit Application on my behalf. I undorzt"this aulhodzo0on is valid far <br /> one tj)year and is limited to the work Plan dat"on the front page of this applloiedan. <br /> s-17.2000'-" <br /> Post-le Fax Note 7671 oa Q3 All <br /> Fro <br /> Yo ' <br /> � Co. <br /> @P <br /> plan <br /> Phon&ft jt.,j -�o-j$'�lo' Phan <br /> Fax r5 / 0, <br />