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FROM :"West Hazmat FAX NO. : 19166308613 Sep. 10 2001 11:00AM P2 <br /> S/10/01 MON 10.19 F_1X 1 916 881 0430 SECUR SACRAMENTO <br /> low <br /> { �Joo2 <br /> San Joaquin COunty Environmental Noalth Servicas, <br /> Unit IV Wrlt Permitliaatlan Su <br /> APP ppiemerit <br /> JOB ADDRESS: _S�a '� / �cu/ar_ PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD� <br /> I hereby affirm that I am licensed under the provisions oi-Ch Vter 9 (coenmenniny with Section 7ol]D}of Grvision <br /> r <br /> 3 of the Business and Professions(;W,3 and my license is in fi.pl force arid©ftect. <br /> Licenr.P#: S S <br /> ���.� Expiration hale <br /> Date:: D�_-/6--o ! Crr^ <br /> .. - ontracto : � <br /> _ �5 i <br /> Title' <br /> Printed nartYt1__r 1 c�..srt-�� f� • _ - diuFtnn>�- _ <br /> WORKERS' COMPENSATION DECLARATION <br /> I herehy affirrn under penalty of perjury nnP of the following dedaHltions- (CHECK AI.L I'HAT APPLY) <br /> _I have rind will maintain a rArfifk:ate of consent to self-insure;for workers'comp vis Htinn,as provided for by <br /> Setion 3700 of the i abor Code, for the performranrr-.of the work fnr which this parmit iy issgupci. <br /> .111'"" <br /> ./I nave and will maintain workors-cornperesntinn insurrarice.a,required by Section 3700 of tree Lahor Code. <br /> for the performance of the work for whicri this Lietrmit is iatruad, My worker:,'eornpcns.alion insuranre <br /> i carrier and policy numbers oro: <br /> Carrier: i >�� jus Policy Number: �'L tj�S✓6 P z.)q I <br /> _ :. ......_ ....--- -- <br /> I certify that in the performance of the work for which this permit in issued. I shall not employ any person in <br /> any manner so as to become subject to the woikeru'rnm(lensation laws of California.and Mree that if I <br /> should becumL+subject to(tie workers'corn perissation provisions nf Section 3700 of thei I Thor C:ndr., i shalt <br /> forthwith Comply With ThOSe ruovhirns. <br /> /0 , - Slgnatur�t: - <br /> - <br /> �- <br /> Printed Name: 1 icy <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 16 UNLAWFUL,AND SHALL SUBJECT <br /> AIN EMPLOYER 1'0(;HtMINAI_PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (Sloo,011o.),IN ADDITION 10 THE COST OF COMPENSATION,INTEREST,ATTORNFY'3 FEES.AND DAMAGES AS <br /> PROVIDED FOR lid SECTION 3706 Of THE LABOR CODE. <br /> ^''� r - bA�d-tl 7'� _ (seonature ofC-s7 licensed authorized itpreseettative), <br /> homer authortreer(print <br /> to Sign this San Joaquin CoUnty Well Permlt Appih=fian fill my behalf_ t undorstnnd this authurisotion Is valid for <br /> one(1)year and Is Ilmtted to tlto work plan dated on the front pine of thiz application- <br /> b-17-20001111111 _ <br /> pplication_b-17-20001MI <br /> "*Wd N0013 1­11JI3 t:I;vE89ti6HT SS=f...i tr41V!s.'x r1 a <br /> J <br />