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1 1:2 8 AM HP LASERJET 3200 ) zt zoot 1: .1.d 2094993433 j P.1 <br />FIFTH FLOOR <br />PAGE 83 <br />3 of <br />Lice <br />Dat <br />Printed <br />I hereby <br />JOBiSliii:krbWssi-e"2.g <br />San kan9ijoigliWegnicgAinnenrigitaliigstiiihsgV4Fceese, Utqg ikYvVvefili3 P erftnii3INSViS71VunpANVMmen t <br />II ki w)'t s(Di. to\./ owRigfiliTsweI,Af?-6 2- <br />,57(7,da-3-,1_,. ,ziai9s,d <br />LIUMlitfa6OCIIINIACIUM DEM:MARIO 4..Cti; D) <br />I he I etch,eaThroftinrattha Hi 4 telnZglatAISOlthglpi9F9t6ltiMsciff6406qtt4.%(fcetrtIlltitrfittgrittbv§FIciitartggl44966114#151vtsion <br />ttielogt§ifiel§41€4t413 069409@nliliirri8Sffire4iii? dil f6re-eaflflect. <br />welp.se#: (-7'2 1 ("j1 5-- 6: .raltil8P1 Date:. /13 do (1 i <br />.Date: eY-?/ó Contra tor / reg ntract r: <br />Signature: Title: <br />igri . ature: if r•:,, , . ., Primo name: <br />name: ( <br />WORKERS' COMPENSATION DECLARATION <br />WORKERS' COMPENSATION DECLAR.VON <br />I hereby affirm under penalty of perjury one of the following declarations:(um ts ALL THAT APPLY) <br />flf-Ii rarauar4e;iPg2gaRfilgWcaileorciefr4MPlitIFIEJP tVi9rBrICerR!gglaiAnT, AtVolgedifPby <br />by <br />de, <br />woo of the Labor C4ode, for the performance of the work for which this permit is issued. I hajt HI maintain a certificate of consent to self-insure for workers compensation, as provided for <br />" c a44%9K9A9rilaqkiiincriRgkerfOrctAriNggfliffh41§@rtiActigPa'afft4diftiditiyiSktilide ECEOCnilf ithisIseled.Code, <br />for the performance of the work for which this permit is issued. My workers' compensation Insurance <br />havtawi4tilliF060iminYfitElwasecompensation insurance, as required by Section 3700 of the Labor Cc <br />or the perform4ce of the work for which this permit is issued. My yoork:fs.'..,cpmn?itliarrinsurance <br />anearEi poi r6A1316-ds are . Policy Number: <br />, • 11:certrfy that in the performance of the work for vii9.111.10,1 ezit is Issued, I shall not employ any person In <br />'6n96.1-1 any manner so as to become subj,to-thu-vvvikaric6 Laws of California, and agree that if I <br />pOqiilgli,btlyogudo'ect to the orkers' compens tion provisions of Section 3700 of the Labor Code, I shall <br />cell614114111 i,cry.flraeoRA.vwri< tor whi. h this permit is issued, I s all not employ any person in <br />zny manner 1 a recome subject to the worke,: co ).ensatio, la s of ç,IifornJ and agree that if <br />. -0cil becr-'.- jet OG-the woElignitopecipen/ ion ./. ./. -.1.,... 4 ..... pfLp of the I ahnr cnria, I sh ah <br />Dat:: <br />WAR <br />P °VIDE <br />1, <br />orthwith co ply with those provisions. <br />7n 4- -' Z,u4(-60\1 Printed Name: <br />Signature: <br />WARNING: FAILURE TO SECURE WORKERS' • ' - ' - • I' • - ••• • • Er. - • , <br />AN EMPLOYER 70 CRIMINNJTINAlt-MS.AND CIVIL FINES U K P TO O HUNDRED THOUSAND DOLLARS <br />' ($100,000.), IN ADDITION TO THErOgriPtphiP€14SATION„-i '-'-'4...c.iiE.Sirr...t:nr_ORNIFY'S PS. AND DAMAO S AS <br />AN EMPLOY <br />04100. <br />ROVI 1 ED FpR IN SECTION 3706 OF THE LABOR CODE. <br />ITINci: AlLuRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />0, - . I AL FtI710..igt.MIVIL FINES UP TO ONE HUNDRED THOLISAN2 DOLLA6 <br />iNAss 01 OT COST OF comPFNgisTictur_WpErillMiorktitcptFittpyr0qertf S AS iliFOR IN SEC ION 3706 0,FeRt_frinCODi( hereby authorize (print name) • 4-- 1 (-- r----22(''--2 <br />authorization Is to sign this San Joaquin County Well Permit Application on my half I understand <br />isaut I ii1 <br />-I,. <br />censedautorizedr4resaniatite, hereby <br />auth <br />to sign <br />one (1) <br />5-17-2000 <br />one (1) year and Is limited to the work plan dated on the front page of this application. prize <br />5-17-2000 / MI <br />this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />year and is limited to the work plan dated on the front page of this application. <br />/ MI