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San Joaquin County Environmental Health Services, Unit IV Well Permit Application Suppfement <br />JOB ADDRESS:-co iç Jv PERMIT SR#: ,061 gt-O <br />4-tft.ofoil <br />LICENSED CONTRACTORS DECLARATION (LCp) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 el the Business and Professions Code and my license is in full force and effect. <br />License #: E.,_,C.Z.—Y,ti._'&__ Expiration Date-.0/ ilTd.A7. <br />Data: I/ /7/0/ Ccintractor: elxrel;2? _at-MVP' t re.."1")>,47 <br />sign2l:1.1re: .1frtikt.- Title: COSPI:lef-arAr_azzesve,... <br />Printed name: _."-- firtoo2ePr—* <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury ono of tho following declarations: (CHECK ALL THAT APPLY) <br />KC <br />K <br />t' have end will maintain a certificate of corent to se-Insure for workvrs' compensation, as provided for by <br />Section 3700 of the Labor Code, for tha performanoe of the work for which this permit le issued. <br />I have end will maintain workers ' compensation insurance, as required by Section 3700 of the Labor Code, <br />or the performance of the work for which this permit Is issued. My workers ' compensation insurance <br />carrier and policy numbers are: <br />Carrier: ,vekci- e fi.„..,6„,- Policy Number: _We, • _e 1 (061—cpc, <br />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 become subject to the workers' compensation laun of Callfornla, and agree that If! <br />should become sub)nt to the workers' ccrnoonSation provisions of Section 3700 Of tile Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: f it7/0 / Signature: <br />Printed Name: CA,' Pete..? 44" <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE 14 uNDRED THOUSAND DOLLARS <br />IS100,000.), IN ADDiTION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND Ck,AmAGs AS <br />PROVIDED PPR sECTIoN 3706 OF THE LI QR CODE. <br />pf 1:17,117gr (signature oft-ST licensed authorized representative), <br />hereby Ruthortte (print name) <br />to sign this San Joaquin county Well Permit Application en my behalf, I Understand this authorization is valid for <br />one (11 year and is limited to the work plan diatod on the leant page of this application. <br />S-17-200u I MI <br />Fmnft, <br />Ji4a4m 25 7146326754 <br /> EA I <br /> PAGE 07 <br />NOV OS 2001 17:04 GREGG DRILLING <br /> 9253 1 3030 2 <br /> P.2 <br />1a/06/2001 ee 7145326754 <br /> <br />EAI <br /> PAGE 07