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Nov 18 2004 11 : 57AM vi- ex, inc 5 687679 p. 2
<br /> San JoAquih Cqunty'>rn"vlrortmental Health bepal//E/l —e/11t WriCk IV Well Permit Application Supplement
<br /> JOB ADDRESS: PERMIT SR#:
<br /> LI Nb ty
<br /> _ON tRACTORS`---O CLARATION (LCD)
<br /> I hereby affirm thata*ai'n jiceilsed under th .e provisions of Chapter 9 (commencing with Section 7000)of Division
<br /> 3 of the Business and 'Pe", scions Code and my license is ir? full'fcrce and effect.
<br /> License#: Expiration data : a Ub 5
<br /> -----
<br /> Date: ContractorC
<br /> -- � ' �
<br /> Signature- IV--
<br /> Printed name; . h. i Air
<br /> Wb1K` RS' OhI11NS1 `N:QCLARATION
<br /> I hereby affirm Under pehpltyi Of.perjury'one of the follgwing: li + Ora orm: (CHECK ONE)
<br /> _! have end will.titalrrtairt ceCtificat+ .of.-COnsePjt`to'se `fji ► i Ypr vyprkers'compensatign;-as.provided for
<br /> by Sectloti 3700 of the LabGr s✓ode, for theport©i�rr5srice of'tfia'wo.Irk for which this.permit is Issued.
<br /> `�►�I have and'will Mainxa`n`iivwrk 'com s ion! stf e
<br /> :! erg:• p0n#qat.., n;. ,rar cs- ,as,;iiaqulred by Section 3700 of the Labor Code,
<br /> for tt;g FerFoCt;^once:i f3 a;vvdek for which_this paimit ls Issuso iu�y tvorkers' ccmpensaticn, insurance
<br /> carrier.and polic�i riurrbers arse:
<br /> Ni°°iri5per -_-��-- j' � ��• 5
<br /> i certify thatinthe pei pfrl am `pf,the':worlc.Yor�nih,ich'#hIW 'im' t:ji.'lssued, I shall not enl to ara arsoi7 in
<br /> ?. P y y P
<br /> eny mertfer sa ae;sio ti`itrri8 stif�iact:#o the Viiorkers';crignsrti Xaws of California, anis .agree that if I,
<br /> should pe¢ome;e%j fjeot t¢:the woiicrs'ocmpenseti prbvrsipn; 'o lection 3700 of.the Labor Cade, I Shall
<br /> farfiiwith coma'. .' ,
<br /> ply Virittl`tlio$e provisions:
<br /> xplra#il0"' r Si9inatur�� �`���
<br /> Oats: 1. �a :::.' .: : ,
<br /> a :• ,. -
<br /> aPrined Nattiie: A a� r->
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<br /> W'. N . I IS UNLAWFUL',AND'SWALL U9JECt
<br /> A.RN.N.., ,;..:;., .:.,y1. ... R1.:c P .M .::� s
<br /> AN:EMf3 OYl R1'O.Cf#1�IA Ng1 1 )wN i�:TJ .1111 b: 11/1 IYai R!" ¢: ; . I UNDRED THOUSAND poL1 ARs
<br /> iAL?11,01 Tt]'F1!I :CSTA,I Gt�Mir� I�, k#I ;Ilii1'Et�f,') 'T`TORNEY'S FEp8,AND DAMACaES.AS
<br /> PFtOVIQEI�1=pR IN 5(.�'r'IdN;.3'>'t1B OF THF,-:4AQR,OOJE,`
<br /> THO t t 01"t `'HEI TH�CII+I '�• •I' IND PERMIT APPLICATION
<br /> t iJ i ...ei,"ni.11 of C-87 licensed authorized.rs resentative),
<br /> hereby authorilYe(print nenile),l, r�� '::�:��L" a�j•r•�'„�1• ~�;r• . . .•
<br /> to sign Nile San:Jo�igU h�C�nity aireH PerriiifApplicaIlan Oi Ittj�gptiAff: layrderstand thla authoriza#ivnas valid for
<br /> one(1 j y�asr and' I nilbtid 1io the vrerk. ::� : :°as`a lication.
<br /> llsi.) p�ui•debad on ths 1'rorit�p��e`o�th:.. pp
<br /> $-t 8-00/MI ti r
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