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07/10/00 MON 164WAX 1 911#,.1 0430 SECOR-SACRAMENTO C:) 1&014 <br /> 04/20/2000 08:23 2094663 FIFTH FLnM • c..PAGE 04 <br /> r <br /> N <br /> SanrToagain�brtn;isr:Environmental�iealthServrce�; UhIt1M1�YIAftrrra9�0p'IPea6oYf uppknieat <br /> b$l(DDRE$S z356q 's 5'ankr Fc �A P R#AkT $I LV r� <br /> AN Z44, 07P -Oil 7.3565s s"rk'V-kk 24q-0&&-0L?- <br /> LICENSED <br /> 49-666-OZLICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby afinn that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: SS rf 9-15 Exp1'ration Date: 01- 31- e / <br /> Date: 7 ' IU- 6b Contractor: West a - Corpow"rm, <br /> Signature. /4, L-r Title: We-6r6A)-tt- fir` <br /> Printed name--ger-1.42!1?— <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 /> Section 3700 of the Labor Code. for the performance of the work for which this permit is issued. <br /> have and will maintain workers'compenbation 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: /�✓yb/�4581LfL16ao <br /> _.efcertlfy that In the performance of the work for which this permit is issued, 1 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 /> Dater D :4--/l` O O Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FDR IN SECTION 3706 OF THE LABOR"00 -_---___ _ <br /> r <br /> (C-571 licensed authorized mpresenti tive),hereby <br /> authorize aF'tr /r'u aH 7Yri s C s e to/a_ <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1) ear and is limited to the work plan dated on the front page of this a li"tion. <br />