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FROM : West Hazmat <br />a2/04 02 MnN 13 <br />FAX NO. : 19166388613 <br />: 12 F'ai 1 9l6 043(1 SECOR SACRAMENTO <br />Feb. 04 2002 03:12PN P1 <br />IdloO. <br />ORIGINAL <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: let -1 W G taNr Sr, LCA. _ PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hareby affimt that 1 r)iTI IiCcn;;0d urider the provisions of Chapter ft (commencing with Section 7000) of Division <br />3 of the business and Prufus eons Code and my liecnsea is in full force and effect. <br />I inonse ll: ,cl 7 �j Expiration Uatd: C5 /- 3z -,02 <br />Date. 0 2- - O -o Zr _ Contractor: i 42 4k4 Y4— <br />D•j.4c� C o. gra <br />3ignature� TitlQ�a✓GL J�J�tN�tt�tZ- <br />Printed name: '�� e•-i/I`r Df C�rvt'1-� <br />WORKERS' COMPENSATION DECLARATION <br />herb affirm under penalty of penury ono of the tollowin9 declarations (CHECK Al t THAT APPI,Y) <br />-- 1 have and will maintain a curlificatu or curisent to self -insure for workers' compensation, as provided for Dy <br />S�Clion C700 ul the Labor Coda, for the rRrformance of thG work for which this prrrnit i� issued <br />_have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for thti perfornuim.e of (tie) work for which this permit Is issued, My worker ,' cnmpensarion insrirance. <br />Carrier andpolic numhorn wo, <br />/,' C Policy Number: _ 22 6J 43 Vf 6?Z7Y 1 <br />Certify that in 1hH performance of the wnrk for which this permit is issuod, I shall not omploy any person in <br />nny manner so as to become subject to the workers' cornpansation laws of California, and agree that if I <br />should l,eScoirie suh1e(,,t to the workers' Compensation provisions of S@ction 3700 0 a" 6bor Code, I shall <br />forthwith comply with those provisions, <br />Date: 7 b Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAwrUL, AND SHALL SUBJECT <br />AN EMFLOYFk hD CRIMINAL PENAL'i IES AND CIVIL FINES UP TD ONE. HtINDRED THOUSAND DOLLARS <br />(SI 00,000,), IN ADDITION TO THE COST OF COMPENSATION. INTERCST, ATTORNCY'S FrrS, AND DAMAGES A5 <br />PROVIDED FOR IN SECTION 3706 OF THF I AROR CODE. <br />licensed authorized representative), hereby <br />autllOrl%rl �f/ 14 A*e Q rc op- y 'z <br />to si(in this I -an .Joagi Gln County WQII Parmit Apptiratinn Ort my heh3lf, I Lifiderstand th1& aidhorization Is valld for <br />one (1) year anti is limited to the work plan dated on the front page of this application. <br />5-17-20001 MI <br />