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04 / 27 / 2004 15: 49 209 - 579-222. 5 MODESTO ATC ! PAGE 02 <br /> San Joaquin County Envirenmehtai Health Services, Unit N Wel( Pafmit AplpilcadAn upplement <br /> ! JOB ADDRESS :� ERM9T SR#:� <br /> II <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that I am iicensed under the provisions of Chapter 9 (commencing with Section OOD) of Division <br /> 3 of the ausiness and professions Code and my license Is in full force and efffe�cctt, <br /> Lioens® 'k: t_ ! r f.7 Expiration Date: _�pp1, 1121 <br /> -yc-- -- <br /> Date: Contractor: ` r <br /> Title: <br /> >S$ <br /> Prantednome: ��� ,J�, �._i..c( <br /> V4i(7PIKERS' COMPENSATION DECLARATION <br /> I hereby atwisrm under penalby of perjury one of the following decisrationC (CHECK ALL THAI APPLY) <br /> I halo and ill maintain a eertifiCa;e of consent to self-insure for workers' compensation. s provided for by <br /> Section 370o of the Labor Codea for the performance of the work for which this permit is Issued. <br /> 1 have and will maintain workers' compensation Insurance , as required by Section 3700 a I the Labor Code. <br /> for the carfcrmance of the work for which this permit Is issued . My workers' Cempeneatlo lnsurance <br /> carrier and policy numbers are: <br /> Carrier; / � Policy Number: t1shl <br /> V� d certify that in the performance of the work tom• which this permit Is issued „ l not em ley any person in <br /> any manner so as to become subject to the workers' c®rnponsation laws of California , an I agree that it ) <br /> should become subject to 'Ihs workers' compensation provisions of Section 3700 of the L tbor Code, I shall <br /> forthwith Prinplywirth those provisions. <br /> Data: „( �_ Signature! �� <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE `IVORKER9' COMPENS�VERAGE M UNLAWFUL, AN SHALL 9UFJJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED FOR ADDITION <br /> TO HE COST <br /> OFT OF COMPASOR CODE" <br /> ION, INTERESTr ATTORNEY'S FEES, D DAMAGES AS <br /> SECT <br /> �(�t 7 licensed authorized rape entstivs), hereby <br /> to sign this San Joaquin County Well Permit Application on my behalf„ I understand this authol 12ation Is valid for <br /> ono (1 ) year and Is timfted to the work plan dated on the front page of this MPPllcstton. <br /> s•17QOga iMl __--- -- - -- "� <br /> 2 ' d STLSETESZ6 — —u---`-'-u0pleN RjeW -- dET 140 b0 4. 2 Jolu <br />