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Jun 24 02 02: 15p Warr Woodward 1 -707-974-5677 p. 2 <br /> San Joaquin+Cotaft ErMrornMnWl HwIfth Servir:es,Uri N Well Permit Application Supplement <br /> JOB ADDRESS=PGS E� WH.LSKE Y �L'G u6 H PERMIT SR11-- GC) 3 O LO <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that i am licensed under the provisions of Chapter 9(convTwm=V with Sec ion 7000)of Division <br /> 3 of the Business and Pro ssions Code and my license Is in flip force and effect <br /> license C -S7 71yo?1 Expiration Date: <br /> Date '2y= o` co WoolDlw Iik2 t�(.r_I►� <br /> Signat ire: Title_ O pe jeATtoN% M RNA 6 M <br /> Printed name_ <br /> WORKERS' COMPENSATION DECLARATION } <br /> I hereby affirm under penally of perjury one of the foitowng declaratiom (CHECK ALL THAT APPLY) �I <br /> I have and will nv*vlan a cerffimft of consent bo sell-instm for woftters'compensation,as pied for by. <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued- <br /> 41 have and vw1 main a workers'cornpensabon rnsurar M as requited by Suction 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'comPermation maurwx> <br /> carrier and policy numbers are ! <br /> Carden. STATE FEMjA Pogey Mumbec 002-02-56 1 <br /> I certify that in the perfonmar ce of the work for which this permit is issued. 1 shalt not employ any pew in <br /> any manner so as to become subjed to tfte workers'co"gensabon laves of California,and agree ttrat if I <br /> should become subject m the worfcers'compensabon provisions of Secbm 3700 of the labor Code. I shag <br /> forthwith comply with those provisiom <br /> Date: i!�-Z�-G Signatum <br /> Prod rye: -"je- Fees moo'^- - <br /> WARNING:FAIWRE TO SECURE VVOR10=RS'COMPENSATKM COVERAGE 15 t11 L"fftM_AND SHALL SU8JECT <br /> AN EWLOYER TO cROUMAL PENALTIES AND CMI.F MES UP TO ONEsTHOUSAND D LLAT 6ES� <br /> p�Ro�vIDEo W A�gt70�'!ON 3706N To THE�THE OF �INTEREST, I <br /> l <br /> signawre ofCS7 licensed authonzad represeNnH►e?,, <br /> Row- <br /> to sign this San Joaquin County WeH Pennit Application on my betcvlf_ I understand this audwxt mdm is valid for <br /> one(1)year and is tunited to time work pan dated on the front page of drls apPRcatiorL <br /> 6-17.20001 M <br />