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^ it <br /> r <br /> Ban Joaquin County rEnvironrneniWHeafth 6 vicar-,unit iY Well Pe.rtnit Application Supplement <br /> JOB ADDRESS: - PERMIT SR#: <br /> ' LICENSED CONTRACTORS DECLARATION (LCI]1 <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(tommoncino with Section 7000)of Division <br /> 3 of the Business and professiorm Code and my licenae is 1n full force and effect. <br /> Fxpiratlon Date: <br /> Date. y' a f Contractor.__ L'3 i /��f-Lr{�tr'+c r�•.rE C,�aR v! <br /> Signature: • !/'` / Ttti _ idr,M fii�r A-6 <br /> Printed name: �hF+7:►aJ° 4 fi.#rCl7� <br /> WORKERS' COMPIENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaradants: (CHUCK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to sell irisure for workers'compofwatlon,"provided for by <br /> Suction 3700 of the Labor Code,for the performance of the worK for which this permit is i"and. <br /> _Iznave and will maintain workers'compensation insurance,ab re=quirec!ay Section 3700 of the Labor Code, <br /> W the performance of the work for which this permit is iHsued. My workers'compensation Insurance <br /> carrier and policy numbers are. <br /> Cartier: r[ LZ•�d+�-5�__ . Polley Number: ✓J�'� �Sl�t.s ijr L GI O <br /> _I e"fy that in the performance of the work for which this parmit is issued,I $hall not oniptuy any person in <br /> any manner so as to become Subject to the Yd"ers'Compensation Dole of Califomia,and agree,that If I <br /> should become subject to the workers'compensatlon provisions of Section 3700 of the Labor Code, I shrill <br /> forthwith comply with those provisions. ///1 /J <br /> Cate: G -Oz-0 1 Signature: �-•s! (1 <br /> r- <br /> Printed <br /> WARNING.FAILURE TO 9F.CURF WORKERS'COMPENSATION COVERAGE lS UNLAWFUL,ANG SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML-FINIRS Op-LO ONE IJUNORED THOUSAND DOLLARS <br /> (S1alt;,000.),Iia ADDITION 7U THE COST OF COMPI<NSATION.INTVREST,ATTORNEY'S FEFg,AN17 RAMAGES AS <br /> PROVMED FOR tN SECTION 37GS OF THE LABOR CODE. <br /> c0LPrV A. _(C-V t1consed nutharlmd rapeesentwive),heroby <br /> autrrorira /G G i�L 7' «f ✓ +� ( er"1� � <br /> to sign this San Joaquin County Woil Permit Application on my behRIC l understand tNe auttsnrittafon is vadld for <br /> one(i)year and is limited to the work plant•Osaod on the hont page of this appllradott. <br /> �3��CE � � <br /> JAN 15 2003 <br /> ENVI RON[41 ENT-HEALffi <br /> PERI MIT/SERVICES <br />