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FROM : West Hazmat FRX NO. i 19166_388613 4 Jan. 27 2003 12:42PM P1 <br /> -I 9lltiJ'l.RR1 ®4:31 �09A6t334 FIFTH 171.00r 04 <br /> San Joaquin County Environniontal Health Sarvices, Unit IV Well Pa mit Appiication Supplement <br /> JOB ADDRESS: <br /> r, ,mss - _L4 Wa;A&4&.-a_ 5&Aa-jPERMI1 SR#: <br /> Pa. .; <br /> LICENSED CONTRACTORS DEGLAR ION (LCD) <br /> I hereby affirm that I um licensed under the provisions of Ghlapt r 9 (commenting with Section 7000)of Divisk)n <br /> 3 of the Business and Professions Code and rTiy license is in full force and eff)-cl. <br /> #: CS'q -xpiration 1:ata; . a/ 3L ,6 <br /> Date.: 0/- Z7-4,3 Contractor: <br /> 1-f A —". 'JI& <br /> I Signature- 01 TitIw_ 61joJ-4_(- A44-al-J A-6&TIL- <br /> Printed nari?A, xw 44a vi, <br /> i61 <br /> X WORKERS' COMPENSATION DECLARA-110N <br /> I hereby affirm undeupenWly of perjury one of the following doclaratiorts: (CHI XK ALL THAT APPLY) <br /> —I have and will maintain a certifinn tH of nnn sent to self-incur fur wotkorg' compensation, Ai provided tot,by <br /> �t T100 of the Labor Code, for the performance at the work for which Ibis permit is issued. <br /> I have <br /> and will maintain workers'compensation Insurance, its required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this pormil is issued. My workarq*nnmponsation insuranco <br /> carrier and policy numbers are: <br /> Carrier. PollcyNurnbar; ZL la-4 IrAf 1-7 *4 <br /> __t4c0ttily thea In the performance of the <br /> Work for W1110i this pormit is (ssuad.!I shall not employ any parson in <br /> any manner so as to become sAoci lo the workers'coropnisation laws&California, and a r e.24-iff <br /> ahould becorrin Subject to the workarti'corylperisation provisions ol'Sactiar 37(X)of t I shall <br /> forthwith comply wish those provisions. <br /> 4.! <br /> Date: Signature: <br /> fff <br /> Printed Name: L <br /> '1711 <br /> -7 <br /> Wr <br /> WARNING:FAILURE TO SECURE WORK15RS'COMPENSATION COVERAG; IS U LAWFUL.ANED SHALL SUF;JF-car <br /> ;F_I <br /> -Ml:FINES UP TO ONE HUNDR D THOUSAND DOLLARS <br /> AN EMPLOYER TO CRIMINAL PENALTIES 6NQ <br /> ($100,000.),IN ADDITION YO THE CO"COMPENSATION, INTEREST.ATTOR EY'S I S. P <br /> PROVIDED FOR IN-SECTI THE LABOR CODE- EY'S FEES.AND VAMAGES AS <br /> /---/< <br /> (sig Lure*fC-57 Ecwtsed author"d represantative), <br /> hereby authorlae(print a) _d, <br /> n 6-1Q40riJ tvl- <br /> to align,this San Joaquin County WOII Permit Application on my be alf. I underata d this autharizzation i6 valid for <br /> one(1)ya8r 100111*limited to 111,3 wokplan dated on the lror,l page of this I on. <br /> 5-17-20001 MI <br />