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02,,e6/2002 11: ;t, 191603un611 --1L_ <br /> ;4*-06-2032 1'402m FrOM-6R01A AND CALDXE L ♦949-4./-01 0 T-7U P 003/003 F-913 <br /> 04/27i:PJE1 12 4° b7�hCJ" 5 _•.� <br /> I <br /> San Joaquin Ceu19ty tsnvirer�M& al Health Sorvi,Z Unit IV Well Permit Appila'.atian'j+spglaunerrt <br /> JOB ADDRESS: <br /> PSRMiT SRM: <br /> Crkc*.•Clmp t CR g52al <br /> I LICENSED CONTRACTORS DECLARATION L( Cts I <br /> I heresy afftrrr, triat I am 6=msed under the provis+oris Of Crlapter 6 (Cornmommo With SOG:i0r`?0�0)of Divislon <br /> 3 o1 the Quaine*a end ProfesniWw COCO end my 11oet'1ee ,s in full face and CMOCt, <br /> Licsnse* - n 1 P_xpir.t'on Data: 1 " - <br /> Dote - Co actor. <br /> Title: <br /> $iianatune: <br /> printed netna: <br /> WORKERS' COMPENSATION DECLAMATION <br /> I hArsDy afriml ,under penalty v?perjury vne of thefoliow+ng dsdarcoors: (CHSCK ALL THAT APPLY) <br /> i 1 have and wA rinainUlln a cort.ficste of consent to self"Asure W wo&4"'Compattasatbrt as provided fOr by <br /> Sedian 3700 pr the Lativr Code,for dhe porformA'wa a,ttte wane for whian tN9 prrrrdt its Issued. <br /> t AaNe ar►C wild mainteln worpensatiorl in�urer,te. as r�uired t3y'Swcoon 3700of thle Labor Code, <br /> for the performance of tate work lar which,,has perMic A 1111UNd. My worKars' Gornper4SGon insulanoe <br /> Kerrier and policy numbers are. <br /> Carrier: Pc licy N umtwr: <br /> I certify that 0.tre wormanco of the work f*r whiaN V t$pQMII IS issued. i @h" nal emp40y any parser►In <br /> ern manrwr so es tv oeaome$object to trip workers'=mpensi►w taws fall rn 3700 of a, ndbGr Code.I she; # <br /> shOUW DOCame svb1601 in t:w orKers'cornponSeliom Q-ov <br /> { forthwith comply wkh those provisions. <br /> Dau ^� _ -0_c�. signature: <br /> Printed Name: � <br /> VYARNiNG: FAILURE TO W-IV i WORPMRS'COMP@VS.AMN COVERAGE IS UI�L,Ar1tTLf AN 811ALL 3UB' <br /> AN EMPLOYfrRTO CRIMINAL pfWALlIli AND CIVIL MN95 Up TO ONK HUNDRED THOUS"D DOLLARS <br /> (11 04111wo.).IN 1ROWt D FORA <br /> UCiION HE GO THE OMPSBOR OSATKK OP WTLIl�4T,ATTORrsns fEE>>r,AND aAMIAoe>a AS <br /> 0.'n (C47lw*rsod euthorwd r►P 'ta*'aj.hsre4y <br /> to sign This San Joaquin Countyftil Permit Application on my bohelt. i undersUod"a&.4hartria°n la vAtildfor <br /> one(t)year and Is N rnftl e0 the work pion dated ase the fro++$Pala of ma epPltcat"am <br /> i 6474M J N1 <br />