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JAN 22 2003 2: 32PM GRE—c-, DRILLING 92`130302 p. 2 <br /> U1/LZ/UJ K'EV 12:01 FAX 1 818 \0430 SMOR-SACRAMENTO 10002 <br /> ' 1 ter, <br /> C`�/LW�Vb'v1 G -t u 5,2_ <br /> San Joaquin County Emrironmerltai Hsalth Services,Unit IV Weil PermltApPticatlon Supplernent <br /> JOB ADDRESS:l,Gsq __ PERMIT SR#: _5 <br /> 164 <br /> LICENSED CONTRACTORS DECLARATION (LQD <br /> I hereby affirm that f am licensed under the provisions of Chapter 9(comme*tcing with Section X000)of Division <br /> 3 of the Business and Professions Code and my license fs in full force and e;;.ect. <br /> License#: Expiration Date: <br /> Date: Contract <br /> Signature., <br /> Printed name: CZ <br /> WORKERS COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> —I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for by <br /> I hSection 3700 of the Labor Cade,for the performance of the work for which this permit Is issued, <br /> ave and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier: Policy Number: �� l22X5— <br /> _✓f certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to beoome subject to the workers'compensation laws of California,and agree that If I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, f shall <br /> forthwith comply with those promslans. <br /> I <br /> Date: Stgnsturo: <br /> Printed Name: t� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED POR IN SECTION 9708 OF THE LABOR CODE. <br /> f, (signawre otC 57 lleensed authorized representative). <br /> hw*W authorize(print name <br /> to elfin this San Joaquin County Wt ermlt Application on my behalf. 1 undara4nd thio au 1lzstfonla validfor <br /> one(1)year and is Ilmttsd to the work plan dated an tate front page of thin application_ ; <br /> 17-2000!IAC ' <br /> 1 <br /> I <br />