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Sen Jcsquln coun <br /> ty Environmaottl tiaaa th neprbrtinant Unit IV WCfl (Til ypiicetl� plernbnt <br /> JOB ADDRESS: 2PERrlT SR# OS <br /> -&A <br /> 1 LICENSER CONTRACTORS DECLARATION <br /> I hereby aMan that i.am licenced under the provisiorm of C hapter 9(moi newng with Section 7000)of Omsion i <br /> 3 of the 4usinaiss and Professions Code and my liciem. is In folf twat and Fffort. <br /> License 01, ,13 C r�Ls ._ Eypir.ahon Date NAW <br /> Signatuee "; i Glx-�{` TitteI i 1 <br /> Printed name: r`- <br /> r <br /> WORKERS` COMPENSATION DECLARATION <br /> s <br /> I hereby atfifimt wider ponaliy of poury one of tho following dedarotions: (CHECK ONE) '- <br /> _ I have arFd vAl maintain a coruili utte of consent to setfAmura tnr worke.IT' r rnnp(,msataon,.as p,+auuierf foe <br /> by Section 37DO of the Labor Cade,forflte performance of the work for which time permitis issued, <br /> I have and wt31 masirr(a(a Yaegkars'ramp.=.nsati,-,n intcaarattca,as requited by SocItIon 37W of the Labor Code, <br /> for the pr-rforma oa oil the work Tw ivi:trii this permit is is heel, My worketV compeiinatkai insurance <br /> cattier and poky nu mheta gra: <br /> Carrier 1 z.:r: E„( Policy Number r id'4?,'^°.}r`1(t ._ l.,g,., "� ,, f <br /> I certify than in the per iirrmance of the work for which this permit is IssUod, I sha3l IRA employ any Persian in <br /> trsy nietitt�asla Its szmjecf.Tat t,IN3 wtarktara'rxwrt�`arisat3oat taws of Cotifotr4la,acrd el tt I <br /> shou"ldl become subjoct to the worths'oempensation pravisiorct of Scotian 3700(vf die.Labor Code,I shall <br /> torfhwilIn pormly ai a prMision s <br /> ,P r <br /> Expiration netec M0 d Signature <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'rOMPENSATION COVERAGF IS UNLA.WVd L';'Aliln SHALL SUBJECT <br /> AN EWLOYER TO CRiN3tA.t_PENALTIES AND CIVIL FINES UP TO ONE 44UNDRED YHOUSWO DOLLARS <br /> (tr4ftOtlU.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEYS FEES,AND DAMAGES AS <br /> PROVIbED FOR IN SECTiO^t a nits OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C47 $IGNING P-MIT APPLICATION <br /> r <br /> l <br /> Isignaiora ofC-67 licemcd uutherized relitasentatl"), <br /> /', <br /> inpgrhonza to"t name) ENNf C7 ��� I <br /> � eU SCO <br /> —' l <br /> to slop this San Joaquirt eowity well Permit Appdfa.allan an ate bahan I anderstand this meehorizotion is valid for <br /> attic(i j year&art lac:limited to Ilia woo ptAn dated on iiia trent p:W of thls oppik ation.. <br /> KIN)Aow9 141 <br />