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SENT BY: SPECTRUM; 5-113- 1 12:55PM, 46513773 => r i #212 <br /> Sacra ,Joaquin County Env iironnienta1 Wealth Services, Unt1 IV Welt farm 11t 1.Applica. lort Supplement <br /> �10121 ADDRESS: � cJ ��"� I�'�'`�� PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION {LCD} <br /> i hereby affirrir that I am lic:o,1W—d Under the provisions of Chapter 0(Commencing with Section 7i 00)of Llivision <br /> 3 of Ili t Business and Prafessions Cork:and my IiCense is in full force and effect, <br /> License 7#1 1 2 1 E.,fiExpiration Date: 04/ 30/2003 <br /> Date- C Cour°ai:it,x: }tyc c:Li-Lrrn�y I Qr'�t ion <br /> _C)p:Qrationk; Maria et, <br /> Sir,Jatattare: .y . <br /> Printed name: *nd <br /> tar: t;a 0r' aw t:{r7:c.i <br /> u —......,.,.._,.�_.�....�.0 <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirrn wider penalty of peritiry one(0 the follcrwinq declamations: (CHECK ALL THAT APPLY) i <br /> i <br /> w I have and will Inairitain a c:f,rtlfcateY of consent to Self-insure for workers' compensation, as provided fir by <br /> Section 37(X)ref the l..atxx (.`odr?, f+x thE) Fx�rformance of thework for whish this pemlit is Isstteci <br /> I have and MI maintain worker; 4 c;ompon;,ation insurance, as required by Section 3700 of the L aWr Code, <br /> for the F�rforrnance of the work for Wiinh this permit is issuecl. My vvorlcers'coinE)erisedivn instirance <br /> Carrk�'r and policy numbers, :are:: <br /> Carrier: i'a3ri M<al c.�z_ ;i, ;t Policy Number; ;3i'JGU3 �75f3{lC3 <br /> s <br /> _ I certify that in the perrrir ilance of the vr)rk too,which this permit is issued. I snail not employ any pe wi in <br /> any manner so as to become ski0je J to tho workers' compensation taws of California. and agree that if I � <br /> shoutU bec xne subject to ttw.workers' compensation Prov ions of Section 3700 of the Labor Code, I shall <br /> fofffiv ith c(xiiply with those provisions, <br /> Date: 55"- 1 . I Signature: t.w, 1 �~'"" ....., . . <br /> _._ ............ <br /> - E <br /> Printed Name: 131 C' wlcjc'c:i <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL SU19JECT <br /> AN EMPLOYER TO CRIMiNAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100"0.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3TO6 OF THE LABOR CODE. <br /> i <br /> If I,sr trric:la r_ r .aw,r i :5 s..i:i i:�i' ::�E_ie c f.L uni Lxi�Lc�z-_taigna ore aiG-57 llCerls6d authorized represerttetirro <br /> tpr►ntname) <br /> Iirrob authorize ._...f"fAL�,.--- L°.-J[�..� <br /> to sign this San Joaquin County Well Pamiit.Application on my behalf. I understand ibis authofixation is valid for <br /> one (t)year and is tiniited to the work plan canted on trio front page of this application. <br /> 5-17-2000 f MI <br />