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10/23/2007 15:40 2094' 433 EHD PAAGE 02 <br /> 1 <br /> San Joaquin County Er►vfrort e <br /> q tay m n l Health Depa ant UnIt IV Well Permit Apollc;rtion Supptetmint <br /> JOB ADDRESS;34o P9WIT SRS#: <br /> LICENSED CONTRACT �S DECLARATION (I_CD� <br /> I hereby,affirm that I am licensed underthe provisions Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Busing and Professlons Code and my llot=i is in full fovea and effect <br /> License#: L#3103 _ ir000n Bate: <br /> Date: 10— (q ""''D-1 Contractor. �C 3100 SAMPt--OCA WG. <br /> fi <br /> Signature: Title: f '0jr-a MAh1 rU EFR <br /> Printed name:„ tUIGIVF145 TkPA,t-k <br /> WORKERS' COMPEN ATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the tiolla,ing declarations: (CHECK ONE) <br /> _I have and will maintain a oertffirate of consent to elf-insure for workers'oompensation,as proviWol for <br /> by Section 3700 of the Labor Code, for the peJin ' <br /> nG*of the work for which this permit is issued, <br /> I have and will,maintain workers'comp�ensrttioariru,as required by Section 37!00 o�f the Labor Code, <br /> i for the performance of the work far which thisIs Issued My workers=mp©nsation insurancecarrier and policy numbers are:k�WTUUL�k. IiCy <br /> I certify that in the performance of the work for whi h this permit is issued, I shall not employ arty person in <br /> any manner so as to become subjact to the worke compensation laws of Cullfomia,and agree that if I <br /> should bacome subject to the workers'compenset n provisions of Section 3700 of thy+labor Code, t shall <br /> forthwith Comply with thg4e provisions_ r� <br /> Expiration o ate, Lo Signature, <br /> Printed Name. �� T P LIQ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEN ON COVERAGE t5 UNLAWFUL,AND SMALL SUBJECT <br /> AN EUPLOYER TD CRWINAL PfikALTIES AND CIVIL Fl UP TO ONE HUNDRED THOUSAND DOLLAR$ <br /> ($100,000.),IN ADDITION TO 711E COST OF COMPENSA ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR COD <br /> AUTHCRIZA'nON FOR OTHER THA C•57 SIGNING PERMIT APPLICATION <br /> 4 signature OfC47 Wensed allthorizod representative), <br /> hereby authorizc(print name) QACtirG tJE T �/�LL <br /> to sign this,San Joagktn County Well Parmli Application n my twhalf- I undorstaAci fhl�uuthmization is valid for <br /> one(1)year and ie limited to the work pian dated ars the nt page of this a0prication. <br /> 8-19-02/Intl <br /> h/22NUt <br /> Z0/Z0 39dd 9NI-1dWVS NOISI03dd bLSVZCZOTS 6E :6T LOOZ/7/0T <br />