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Apr . 29 , 2002 4: 17PM CONDOR EARTH TECHNOLOGIES No - 9363 P . 4/6 <br /> . I . _JG_ -JPt•1 9253130302 r . 1 <br /> W- 11. 2002 101 4AM CONDOR EARTH TECFNOLOGIES No-9197 P 2/2 <br /> San Joaquin County l nvlronrnontaIj4a Iq th Sefyle.�,Unit lV Well ttrrallt A n Supplamant <br /> Pu�b1{c, LCMCk5 ig o } a <br /> JOB �►DQRESS: A--a c peaMlT S <br /> LICENSED CONTRACTORS DECLARATION (L ) ~ <br /> 1 hereby affihm that I ern Peened under tha Provisions of Chaplar 9 (commencing with Section 7000)of Division <br /> 3 of the Business ana Professions Cade and my license is In full Force and effect. <br /> Expiration Dote: <br /> Date: 4Z17 A,-L- <br /> Contractor: <br /> slgnatum / , ��- TItI*: <br /> Printed name. �7 � <br /> WORKERS'COMPENSATION DECLARATION <br /> I heratl.y affirm under penally of perjury one of the following declarations.- (CHECK ALL THAT APPLY) <br /> ave and will maintain a certificate of consent to self-Insure for workers'cam enation, as provided for b <br /> P p y <br /> Soction 3700 of tho Labor Code,for me performance of t which this permlt Is lasued. <br /> I have and Will maintain warkero'compensation Insurance, 03 requ)red by Section 3700 of the Let3or Coda, <br /> for the performance of the work for whiC> this perm!(is lssueo. My workers'compensation insurance <br /> carrier and policy numbers ere: <br /> Carrier: t1r1 'Policy Number: <br /> I I Certify that in the performance of the work for which this Permit Is Issued,I shall not employ any person in <br /> any manner so as to became subject to the workers'compensation laws of California,and agree that if I <br /> 4IhWld become subject to the workers'CoMpen$ n�av,alons of Sect n 3�of the Labor Code,I shalt <br /> forthwith Comply with those provisions- <br /> Onto: Slghature: .-.- <br /> r , <br /> Printed Name: <br /> WARNING:FAILURE TO SECUFk9 WORKERS,COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SU13JECl` <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP 70 CINE HUNDRED THOUSAND DOLLARS <br /> (;100,1100.),IN ADDITION TO THE COST OF COMPENSATION,INTER93T,ATTORNEY'S FMS,AND DAMAGES AS <br /> PROVIDEAT�OR IN SECTION 3708 OF THE 7018 CODE. <br /> (C3711consed euthorl=d mprasentative),hwetty I <br /> authaNzs \ <br /> 1-j PF <br /> Io eiyn this San Joaquln County Well Permit Application on my bah»tr. I understand th Is authwizallon Is valid far <br /> one(1)year and Is)IM110d to the work plan elated:an Tho front papa of thls application. <br />