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NOV-07-01 WED 02 : 12 PM ENPROB 9165892230 P. 02 <br /> 11/07/2001 11:33 FAX 925 943 2, GE05XN'EC-WC <br /> 1a002/00Z <br /> 11--06-200i 01=31PM FROM TO 19259432366 P.01 <br /> i <br /> f <br /> i <br /> FSan Joagwin County Environmental Health Services, unit IV Well Permit Application Supplement <br /> OB ADDR> SS: 3�5 Q fJ s� 4 j w 3 PERMIT SIS#: <br /> 4 <br /> S <br /> LICENSED CONTRACTORS DEC�-ARATION LCIS <br /> i <br /> I hereby affirm[that I am llconsed under Lha provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the BusinLs and Professlons Code and my license is in full farce and effect. <br /> License 9: -- -''�`� � 7 Expiration Date: <br /> Contractor: <br /> Signature: Title: <br /> Printed name; ^/ <br /> 1NORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty C f perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> i <br /> I have and wild maintain a cartMcote of consent to solf-insure for workers'compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have engf will main taIn.workers',compensatlon Insurance, as requlrad by Section 3700;of th15 Labor Code, <br /> for the De`formance of thO work for which this permit is Issued. My workere,' compensation insurance <br /> carrier anti policy numbers,are: <br /> ��► y <br /> carrier Polley Number-, _ 7�,3�la0 gpoo7j� <br /> I certify that In the performance of the work for which this permit is issued, 1 shall not employ any person in <br /> any manner so as to become subject to the workers" compensation laws of Callfornia, and agree that If I <br /> should.b+;come subject'tojthe workers'compensation p visions of Section 3700 of the Labor Code, I shall <br /> forthwith Corn ly wlth those provisions. <br /> Dente' f/ 7 n200/, Sl�natGf@: <br /> Printed NamQ: <br /> ;'WARNING: FAILURE TO S ECLJFE WORKERS'CONI P�NSAT10N COVERAGE IS UNLAWFUL,AND SHALL'SUBJECT <br /> AN EMPLOYEkTO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION To T1 U,COST OF COMPENSATION,INTERGST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED F IN SECTION 3706 OF THE L-ABOR CODE. <br /> 1, <br /> •57 licensed auth <br /> authorize �orizrepresentative), hereby <br /> �'—' <br /> !o�lgn this 'r<Joaquin Count Well Permit Appiicatlon on my behalf. [ understand this authorization is vatid for <br /> one (1) year and is ljmjtgd to•t <br /> tij9 Wvrk plan dated nn the front pale of t}tis�apPtjcatJon <br /> 5.17-20001 Mf i <br /> i Po' t it�'Fax No.o 767f Oalei C Qr <br /> r' From ` <br /> i � CcJDgD6 <br /> Phgne x <br /> ' Phone 3 <br />