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Apr 29 , 2002 4: 18PMA V CONDOR EARTH TECHNOLOGIES 510 568 7,.7,No . 9363 P • 5/6,2 <br /> APP-0-2002 12123 W60DWARD-:LYDE CINSLL-iANT Sal" rji4 S�bb 1.1 015"lui <br /> an�oaquin County Etwlromnental Heatth Sw0 es.Unit rV Well Potnrit Application Supplement <br /> JOB AUDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that f am lit s9d under the pro-visions of Chapter 9(oarnrnemotrlp with SwUon?000)of Civisit3r, <br /> 3 of:he euxiness and PrcOemions Code and my tieensa is in fedi foroe and olftret, <br /> Date: `} t O �, c�,..- L'.at> ctor V U T—nC� <br /> glgn>ttura. —�5 .l.lr. 1�.tiw r`-� Title: c - Ar �t <br /> Printed name:_-- ! 40<1 <br /> WORKED$'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fWtovoing degpretione. (C1 WCX ALL THAT APPLY) <br /> I have and will rna;nlain a aartifte:d of eyneent to 90-insure for workwx,compensation.as provided for 0V <br /> S'0M, ,r 3700 nr[tie Labor CadQ.for rhe performance.7f trap vmrk fvr 8 is Idsued- <br /> �I Have and will rnaintain workers' compert3smon irssurante,art required by Bt;Ctiea,970th of tlac Labor Code, <br /> rr)r thg r.r,,r,it~14ncQ or the worst for which this petrnit i!issued. My warkelrS'CompGnsolion insurance <br /> ;:ar i,.; ,,.I;..yII 7 it ails era: <br /> Policy Number: <br /> W I cLJr*ML'!in the pertortnaars of the work for which this para;t it issued, I sheet!not ampicy any person in <br /> *ny.'��nnar sn ps to bP^atne subject to the workers't ornpensation hews&California, end agree that It r <br /> i sliou'd beCam u subject to the workers,oomperestien provislonx of 5ftVan 3701D of the labor Code. I smov I <br /> !f fc711f;Y,rh:.)Mply with those provisions, i <br /> rats:ALL04 <br /> fj W Signature:--- <br /> I <br /> Printed NlAia; <br /> WARNING:FAILURE TO$VCVMt9VV0AKEK*,C01A1xeN.$AT10N CDVg"CS IS U14LAWFUI-AND SHALL 90JECT <br /> PN FIVOLOYER TO'CRiMINAL PENALTIES Alit!CML FINIS UP TO Wilt MUNDREC Yf?aaU$ANta COLLAM <br /> 1"f APLIMON T'o THe COST OF COMPENSA11ON,INTEREST.ATTOItWrS fit s,AND DAMAGES AS <br /> CN:Iix� <br /> FORM LASOR COM <br /> _.,,,,-(signature olC47 lieeneed ivt *dzL%d fspresiemativer), <br /> hcrebye4,thori>:t:(pnnit+arn•��� `:7 t, 4' t i � �C�t"`� J <br /> la 21-0 dhia Sari Joage:iri County Wel]Pamit Appheation an my behalf. I uadwstared this muthotia:atlon Is valid for <br /> '3 ;t . <br /> ono��,�xgtf,?sOtl;�l;sritwg7a thew**plan dated oe tbefrpnf page of thin appllballon. <br /> TOTR- P.03 <br />