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04/12/2004 15:51 CLAY7111 GROUP � 12094683433 NO. 162 P02 <br /> APR 12 2004 11 : 03AM I LASERJET 3.200 p. 4 <br /> 94/12/2004 11:02 CLAYTON GROUP 4 142531303132 NO. 150 P <br /> Sen Joagvin County Eunylronmental Health Dapertmont Unit IV Well Pttrmtt Applicsdon Supplement <br /> JCM ADDRESS,. PERMIT SRN: <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> 1 hWOUV affirm that)am 6censeel ander the provlslone of Chapter 9 (commencing with Section 7000)of pivtsion <br /> 3 of the Susineae and Prafessions Cods and my license Is In full force and effect. <br /> klcense aiN C-l; �.5 Expfttion Oat*. <br /> Dale: Gonlra c <br /> 542natu110; Title, o <br /> Panted name• �r ,� �d'" <br /> �T <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pe "Ity of pedury one of the foliowlrg deeierationa: (CHECK ONE) <br /> have end will maintain a ranlfkwe of cnn9ent to$*K-Insuro for as prpvided for <br /> by Sactlon 3700 of the Latrar Code, for th9 perfo manCa of the!work fpr which this pemnlL)s issued- <br /> have and well maintbin w-1,.ira'oompon5aUon inlwranw ala required by Section 3700 of the Labor Cock, <br /> _�-1 <br /> for the performanw of the work for whioh I*permit I*ib5e66d. My workors' compensagon insuranra <br /> e rror and policy numbers are: <br /> Carrier. Wt Policy Numbefn s� 1?/G! 7C�[1 7 <br /> I cettfy that In the pedormanct,of Ire work for which this permit Is Issued. I shall not WMloy any person in <br /> any manner so as to become subj®(Z to the worttarj'compensation laws of California, turd agree that if I <br /> Sfrnufd become eut5jecll to the worx6ra'compensal Ion provilsions of Sacilon 3700 of tho labor Cade, 1 51ad <br /> fOOWth comply m7%those prcmAslcns. <br /> EalplrOtfayn Mata: RSlflnatura; <br /> PHntsd Na'ttis: <br /> WARNIIef6'FAILURE TQ SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL. AND SMALL St.15 ECT <br /> AN EMPLOYER TO CRIMINAL PI!NA6T19$ANO C(VIL FINCS UP TO ONE HUNDRED THGUSAND DOI.LMS <br /> IS101.20M),IN ArOTION TO THE COST OF COMPINSATION,INTEREST,ATTORNEY'S FEES,ANO DAMAGES AS <br /> PROV100 FOR RCSECTION 3706 OF THE LABOR CON, <br /> AUTHORIZATION FOR,-0-,WER THAN C•57 SIGNING PERMIT APPLICATION <br /> 11 (signature OC•57 Ilcens"authorized-mof6sbnoett"), <br /> hereby a uftrls. fprkat nmwl—... <br /> Io xign this San Joaquin County+Well Prrnttl Apptecwtlon an my behalf. I understand this Awthorizotion Is vans for <br /> ora(1)you end Is ttmltod to the work plan dated on the front poen of IhIs appliMlon. <br /> 1242(M) <br /> roZ4,0241 <br /> onnnm� <br />