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Jun-05-01 07 : 33A � r P.02 <br /> 06/04/2661 11:5,1 576-6366 LFR GRANITE SAY• f'AGt by <br /> ,�?o/ F wz ZO <br /> San Joaquin County Environmental Health Sorvicas,Unit IV Well Permit Application Supplement <br /> 00 Z4 <br /> JOB ADDRESS!., PERMIT SR#: 0 2eo5kY <br /> LICENSED CONTRACTORS DECLARATION (1.2) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Piofes&onps Code and my license is in full force and affect. <br /> License* 6s-')— 1 ��0 Q 1 ��E��xpiratioate'.��n D ! '/3]D-o-L <br /> Date: rc -0 t Contractor: J[3/L�!`�� (//11LL1 <br /> A, <br /> —�� <br /> Signature: /1-_ 'L a d[" `i`] Titles <br /> Printed name: WAA(I lJ�'+Ayn t / <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 certficate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Coda,for the performance of the work for which this permit is issued. <br /> I have 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: K <br /> Cartier:-SMTP(- -V"P'7'ZN� 'lk4olicy Number. WC <br /> I 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 become 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, I shall <br /> forthwith comply with those provisions. <br /> Date:_ 6—J:::0r Signature: <br /> Printed Name: i4�1 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVII-PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.h IN ADDITION TO THE DOST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IINJ SECTION 277769 OF THE LABOR CODE. <br /> I, /l/ci +°"-'"'7 (signature,ofC•67 Nsensed authorized repnmenmtive), <br /> hereby authorize(Print name) &A/ Awyz an, Z-FA °1 GuT�1 T lyff <br /> to sign thV-Son Joaquin County Well Ponnit Application on my behalf. I understand this authorisation is"lid for <br /> are(11 year and is limited to the wort plan dated on the front page of this application. <br /> 5-17-20001 MI <br />