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02/06/2002 11: 45 19166385611 DkiLL11Ju i- r- _ <br /> E0-06-1002 10.30am F,m-OPCIV11 LML 4f4i-4i4-0140- T-i60 P 002/703 f-713 <br /> Sam Joaquin County anvtron"ntal Health t>i+rvlcas,Unit IV Well Pormit Application SupplarTwRt <br /> JOS ADDRESS: 54 2- PERMIT sRX: <br /> q5 <br /> LICENSED CONTRACTORS DECLARATION (6 02 <br /> i <br /> I ~> r sffi^rr that i are+ licenesd under the pr0Yi3w!l of cmaotair S(commencin�9 voth Wtion 7000)of Ohio on <br /> 3 of the Rusir.ess and Profesios Code ani;my lk7s is is Ir fate foroe and atttfr►ot, <br /> t,itianse*: A 7 — '1 l ''7 _moi 1 0 , Exptrasdon DeW J - L) <br /> Date: 0 Can rdr <br /> aignatuari: T Itle: <br /> Printed nonne: <br /> WORKERS, COMPENSATION DECLARATION <br /> t <br /> I hereby affirm ender penalty Of pvrJUrY <br /> one o'the following declerrtio.ns, JONECK ALL THIN APPLY) <br /> I neve end wiG ma ntaln a cartJicate of eonsent Ib ssiNnsure for workers'ccmpenaarkm, as Prov dad for by <br /> fSeeAan 3700 of the Later Code,for tee periormonge of the vox-k for whlan this pwmlt iS issuba - <br /> I have and will maintain Q*fGr2'C0MW%Qb0rl insurance.= .►sgw.reo by section 3790 Qlria Labor Cats, <br /> for the p•ridrraatlea tSf the work for which this permit is 3suv0. My workers'CoMpemsatvn•sruwraM0& I <br /> Cerner aceta policy numbora are. <br /> _Ph1 OQSk Q 4 1� policy Nvmb�.r. 1 t ►1. �� �] �..� 1 <br /> h Carriar; _ �— <br /> e.rtify thel in file per'formdr nof the vrork tar wltii0tt;his ee: ssu <br /> m't is isa,1 044 not amptoY any Darsonin <br /> any men-ar so as to beoorte SAW W ht workers'=MpeI" laws of Caiftmis, and eamfi tfitt it I <br /> should oecome subiout to the,worker'eornpensat f%prpvl ' Sactlo tap a!�Lobar Coag. i ihen <br /> rothwith eernpy with those provesio�><_ <br /> l <br /> Data: —_� " 4 a �ignaturi• <br /> Printod Name: <br /> WAR14ING: FAILQ RAE TO SECURE WORKERS'CONIpLItiiAT10K COVIRA06 e3 UNLAWFUL.AND SKALL SUt3JEW <br /> AN E1dPLOYER TO CF0MIM/1I.pW4AL ES AND CN L RN93 UP TO ONE KUNDRED THOUG M OCILLARS <br /> ioG ,FOR aif,>%j TV XFg o r orU18t3R COOP- <br /> 1, <br /> ODI iK MST.AT70RNE'f'9 FESS.AND DAMA <br /> PRO0pdEt;AS <br /> t C.p Nconsed eutheri"d rvpresomativel.hereby <br /> arthoriMR <br /> to sign M+is Scan Joaquin County Wo{I Rerrmit Application on MY behalf, i understand this autobmtlert is valid far <br /> one(t)year and is Il r111tea to tho work plan dated on We front Paas et t hba OPPtic'p^- <br /> i <br /> s-oz-�ooa� <br />