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NGU-15-2012 15: 18 ENGEO INCORPORATED 1 925 866 0199 P.02iO3 <br /> JVW ADDRESS: 7.3 b0 <br /> _L PERMIT PERMIT SRO <br /> LICENSED CONTRACTORS DECLARATION LCD} <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full fore and e <br /> License# t Q 9 C <br /> E Date: <br /> Date; <br /> Contractor: <br /> Signature; <br /> Tide: <br /> Print Name: , <br /> WORKERS COMPENSAI igN DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations. (check ane) <br /> I have and will maintain a ceMcate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, forthe performance of the worts for which this <br /> Permit is issued. <br /> 1 have and will maintain workers' compensation insurance, as <br /> Labor Code, for the performance of the work for which this wired ue Section 370 of the <br /> Compensation,insurance <br /> ranee carie and policy numbers are: Permit is issued. My workers' <br /> Carrier. ►! QTc policy Number. Do <br /> I certify that in the performance of the work for which thisrn _ <br /> Person in an manner so as to become subject to the wodcernlms'it is issuers, 1 shall not employ any <br /> agree that if I should become subject to workers' Compensation V, law of California, and <br /> Labor th e, I shall forthV ComPh/widen those prow PmvisiOn of Section 3700 of the <br /> ' s, <br /> Exp. Date:—4G�4� <br /> Signature: <br /> rte-,.., <br /> Print Name; fwOb: r 4- V I <br /> WAftNRYG:FAILURE 10 SECURE E14 CRMNALPF7ALnF5ANDCMLFNESUPTOSI000VERAGE!S UWAWM4 ND SiAc-UWECr AN EWWVER Ta0,000 <br /> IN ADMMON TO THE COST OF <br /> ArMFNE"FEES,AND DAMAGES AS PROVIDED FPR IN SECTION VN OF TtIE LAriOR CODE. ATW N,iNTEREgT, <br /> i <br /> 0 R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> signature of Cti57 lkensed audirnrirxed re tentative <br /> herBby authorize(print name) <br /> I sign this San Joaquin coo ,I r r, �'� ), to <br /> 4 my Well Penna Application on r"behalf t understand is valid <br /> far one year and is Gnriled t-0 the work plan d a W on the Iron! <br /> Page otTlmiS appii¢aft n. <br /> &dq2" <br /> ew�xw7, W7 <br /> WELL PaRl"AFV <br />