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May 09 01 04: 31p n Jones 5-9451 p. 2 <br /> 05/09/2001 14:20 209 2225 MODESTO ATC PAGE 02 <br /> r < <br /> San Joaquin County Environmental Health Servlees,Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: Zia W. Main 5t �,D� PERMIT SR#: ? 37 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(Commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License 0: //a9:3l RC.-_c:z- Expiration/D-ate:C� <br /> Date: `7 'y Contractor: ��j�f/ 0 V I A2d1_2 y,9A_ 1r <br /> Signature: 711zz!�z Title: <br /> Printed name: Y.iC!111111 i2yu/ <br /> WORKERS'COMPENSATION DECLARATION <br /> I heresy affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certlficale of Consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit Is issued. <br /> l/(have and will maintain workers"compensation insurance,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation tisurence <br /> carrier and policy numbers are: /n�c <br /> Carrier:I"� I o n Policy Number: 1(-73 <br /> I certify that in the performance of the work for which this permit is issued, 1 shell not employ arty person in <br /> any manner so as to become subject to the workers'compensation laws of Caiifomia,and agree that If i <br /> should become subiect to the workers'compensation provisions of Section 3700 of the Labor Code,I shalt <br /> forthwith comply with those provisions. <br /> Dal*: Signature:_ <br /> Printed Name:_ c+JE/y/ QS 1-{ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (3100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES A9 <br /> PROVIDED FOR IN SECTION 3706 Of TME LABOR CODE. <br /> 4Y t Cl �L1-1 (C-37 licensed authorized representative),hereby <br /> authorize ��� <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> ono(1)year and Is limited to the work pian dated on the front paps of this spplleation. <br /> 5-17-?000/MI <br />