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FROM West Hazmat FAX NO. 19166388613 Oct. 31 2002 08:11AM P1 <br /> �dCT 30-2.002 WEU 06: 16 FM hTfON M1CKIi1 QN TiNV FAX N0. 91fi ']Ei'l0 R 02 <br /> San JoarywO County F.nvi7ornniantal Health Services,Unit IV Well <br /> l Pend Application Sup'ppllam nt <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I herel7y affirm that I am licensed under the provislom of Char er 4 (rrunmpnOng vMh SeCAinn 1000) at Division <br /> 3 of the Business and Professions Cotta and my lirnnm Is in full form and o fora- <br /> Woensr.Vf; S S c(`7 7 S _Gxpiratiro Date: <br /> c001(anlnr. �3i irzM�r?- �iu�c.��.�/G <br /> 60 <br /> Printed na .- <br /> _ WORKC.RS' CO CNSATION DECLARATION <br /> I hereby al'frun under punally of perjury one of the followin0 declarations: (CHECK ALL'1'HAT APPLY) <br /> I have and will maintain a ocNificete of wnsent to self-insure,.Mr w(Wkers'compensation, as provided for by <br /> /.^•.action 9100 of the Labor code,for the peltolmance of the work for which this permit Is Issued. <br /> ✓_ ' have and will maintain workels'unnpnnaation inauranx,as ryquifed by 8o4ion 3700 or Ilia Labor Code, <br /> for the performance of the work for which this permit is issued My workers'campensalion insurancr. <br /> ranfor and Dol cy numbers are: <br /> carrier:_ ��G-0 - Policy Number:_2 ✓6 Of L%VI <br /> I certify that In lhh fxufarmrince of thn wnik for which IhK pnnnit is issued, I shall not employ any person In <br /> any manner so as to become suhjecl In lho w0rkers'r4)mpanaation laws of California, and agree that it i <br /> .should Ia:cwnie subject to the workers'compensation provisions of Section 3700 of the I dt>t-w-codc, I shall <br /> forthwith comply with those provisinns. el ( .' <br /> Date: �a.`•3 J'0 iL :iiffnanlre: `� ��„ /� <br /> i'rfnfad NAmoC /� G'fMt•J / , d1 , I w <br /> WARNINO:FAI1.USE YO SF.CURC WORKCRS'COMPENSATION COVCRAGC IS UNI.AWFIII.,AND SHAH SUDJrcT <br /> AN EMPLOYEN TO CRIMINAL PrNAI TIF.ANn orill r1Nrs IIP TO ONr HIINDRrn THOUSAND DOI_IARH <br /> istoo,noo.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'+}EEy, AND DAMArirs As <br /> PROVIDED FOR IN SkC"IION 3706 OF THF I AHOR CODP- <br /> ofCdT licensed authorizes representative), <br /> hsroby autlwrlre if Wirt nnme),,;-?W.,is LC' p,jr <br /> hr sign this San Joaquin County Well Permit Application an my behalf. i understand this authorization Is valid for <br /> one(1)year and is limited to the,.work plan dated on the front pans of this application. <br /> S-f7-20M)I MI <br />