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FROM : West Hazmat FAX NO. 19166388613 Sep. 19 2001 09:41AM P2 <br /> iN 9/19/2001 09:31 2094683433 FIFTH h'LODR PnrF 04 <br /> i <br /> San Joaquin County Environmental Health Services, Unit IV Wolf Po trait Application Suppfamoni <br /> .j <br /> JOB ADDRESS: s4�- (7 / S PERMI SR,# _��T Q•bZ <br /> r' awl cry, C <br /> � <br /> a LICENSED CONTRACTORS DECLARA ION LCD <br /> I hereby affirm that I am licensed under Itle previsions of Chapter 9 (connnen :ing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license Is In full force and off at. <br /> .. . License#, Lxpiration Dale: <br /> n— 0. <br /> Date, 041&9AI Cnntractnr:.-... .1f5�.I..,_ 7I <br /> } i ] Y U <br /> Signature . " (� rine: ibrTL . ` <br /> �7- - - <br /> Printed hand: <br /> WORKERS,COMPENSATION Or-CLARAI ION � — <br /> p I hereby affirm under penalty of perjury one of the following declarations: (CH CK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self insure for workers' 0rnponsation,as provided tar by <br /> q4' '�Section 3700 of the Labor Cade,for the performance of the work fol whfc this permit Is Issued, <br /> ^' I have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Codo, <br /> for the performance of the work for which this permit is issued. My works 'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:_�l�bL --l$�S .. ...Policy Number:--- L.1•S_�VEi t' 47 <br /> �( <br /> — I certify that in the porrormance of the work for which this permit is issued, I shall not employ any person In <br /> h, any manner so as to become subjer:t to the worker^,'cornpensalion laws o'California, and agree that if I <br /> shnuid becemn subject to the workers'compensation provisions mt Seeho 3'/00of the Labor Cade, I shall <br /> forthwith comply with those provfsions. <br /> IOate: 09- /S-O/ .Signature: <br /> Printed NameF t/rrvrl di ` a>tar.rrr J <br /> wwyy, WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS U LAWFUL,AND SHALT.SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE HUNDR D THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTOR EY'S FEES,AND DAMAGFS AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> y_ <br /> )rGr•//I-1C.0 /7 b/LGA C[LN'Y/ <br /> ,,..-_- _(signature ofC-5711c nsed authorized representative), <br /> hereby authorize(print namo)�� � _ C-� J <br /> to Mon tills San Joaquin County Well Permit Application on my buhalf. I understa d this authorisation is valid for <br /> I' <br /> one(1)year and to limited to the work plan dated on the front page of this applica On. <br /> 0-17.2000/Mi <br /> 1�r <br />