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_,9 01 04: 31p n Jones 5-9451 p. 2 <br /> 05/09/2901 14:20 209 `-"?-2225 10� MODESTO ATC J <br /> __-.._......_. ._.-------.--.•--.._...._--- PAGE 02 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit ALWIleatlon Rupploment <br /> JCI® ADDRESS: Zf5 w. 611ai,� st_ R:Fa� <br /> PERMIT SRS �3?� <br /> LICENSED CONTRACTORS ECLARATiON (��D) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(Commencing with Section TODD)of Division <br /> 3 of the Business and Professions Code and my license is 1n full force and effect. <br /> Llcersse P 1oR;�(mr Expiration Date: <br /> Date: Contractor: 'SC LJ ELI I I,2,0nMG?AWL2 <br /> - <br /> Signature: mr L � Title: L�cvR.�L <br /> Printed name: V/L <br /> WORKERS'COMPENSATION DECLARATION, <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> —1 have and will maintain a certificate 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 /> 1 <br /> ^li(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 insurance <br /> carrier and policy numbers are: <br /> Carrier: `?la+e Ntvn Policy Number: Is <br /> I <br /> I certify that in the performance of the work for which this permit is issued, I shelf not employ any person in <br /> any manner So as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section.3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Dale: <br /> Printed Name:_ c Ef V/O C175_,H <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 HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 Of THE LABOR CODE. <br /> t, V 1 Ff (C•ST licensed authorized representative),hereby <br /> authorize (-)7T(1 <br /> to sigh this San Joaquin County Well Permit Application on my behalf. t understand this authorization is valid for j <br /> one(t)year and!s limited to the work plan dated on the front page of this application. <br /> I <br /> 3-17-MO I M1 <br />