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10/18/2001 15:07 209461"-"'18 A WE 5TOCKTON PAGE 03 <br /> San Joaquin County Environmental Health Services,knit IV Well Permit Application Suppiemebt <br /> JOB ADDRESS: 3L Ot � • 1t .��an --- PERMff SRO; <br /> LICENSED CONTRACTORS ECLARAnONL( CDl <br /> I hereby aftm that I am licensed under the provisions of Gh pi ter 9 (commencing with Section 7000)of dhrislon <br /> 3 of the Susine"and Profe oe ione Cede and my license is In AA farce and effect. <br /> Lie:erfae# 1~xpiravol I Date: _ _ o-t gal 103 _ <br /> Date: 1 .. 19t e3 jo j -- Contractor: Mal a <br /> Signature: Title:. 0 <br /> Printed name• <br /> WORKERS'COMPE,NSAT) N DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following d ciarations: (CHECK ALL THAT APPLY) <br /> I herve and w111 maintain a cih fic$te of consent to self-ini ure for workers'compensation.as provided tar by <br /> Se3ctlon 3700 of the Labor Code,for the performance of I I@ work for which thio permit is issued. <br /> —1 have and W01 maintain workers'compensation insu .as required by Sectinn 3740 of the Labor Code, <br /> _` for the perfoCmance of the work for which this permit is! uod. My workers'campenssdon Insurance <br /> carver and policy n//umbers are: <br /> Carrier ,�f� ��� Policy I gumber. <br /> I certify that In the performance of the work for Wch this permit is issued, I shall not employ any pion in <br /> arty manner so as to become s*ect to the warkem'coff iperimflon laws of Calftmis,and agree that 9 l <br /> should become subject to the workers'compene-aton prc visions of SecUon 3700 of the Labor Code, i shall <br /> f6r0twlth comply with those provisions. <br /> Date:���Q' �D� sipffature: <br /> Printed Nanle- <br /> WARNING:FAILUPA TO SECURE WORT MO,COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL 3Ul3JXGT <br /> AN EMPLOYEPt TO CRIT NAL,PMULT1Es AND CIVIL FMS UP TO ON!NUNDPJM T14OUSAND DOLLARS <br /> (3t00.000.),IN ADOMON TO THE COST OF COMPEMATICK It ST,ATTmNEY'S FSS,AND DAMWES AS <br /> FROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> C-67,11cans4d auMar e a representative),hereby <br /> aerthafi`te <br /> to sign this 3W Joaquin County Well P"t Appilaatim an my beftelt I understand this authort mflon Is valid for <br /> one(1)year and is limited to the work plan dated an the ftnt ofthls eeeppllc eon. <br /> 8-'17, 000 I Mi <br /> ti!b abed `9010[ L0-64-100 `•zoco c 6 sze = 'auI `buzTsal '3 5UTT-[TJ0 659J0 :AS juag <br />