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1 09.48 <br /> ' 5j701S.I45577 WOODWARD i�K' LNG 91z� . 289519- <br /> ' <br /> MODIES'TO ATC / <br /> San Joaquin County Environmental Health Services, Unit IV Wolf Prrmtt Aiapiicofiian Suppl*mentYT' <br /> J013 ADDRESS' �kfr�f ��, GCN4 PERMIT SIRS: 06 �Z� <br /> A .: <br /> 4 LICENSED CONTRACT041 DECLARATION (LCDI <br /> I hereby affmm C!,iet � 4Pn ficenixed under the provib'ons.of Chapter 9 (commencing with Seetlon 7000)of Division <br /> 3 of tt'e Business and PrvfWsinrs Code and my iicenss is in felt force and effect <br /> License#: . _ - _Explrstlon Date: U'" <br /> DatA: 9ZContractor <br /> 7Irtattuatr; ._ 'title; <br /> Printed nam** al �o�.$Sla wt <br /> WORKERS` COMPENSATION 011CLARA1110N <br /> I harehy affirm under penalty of poury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and wilt maintain a ceditlo*te of consent to self-Insure for workers'carnperisMion.as prDvided for by <br /> 5ecdon 3700 of he Labor Code, for the performance of the worm for which tNe pefrnit is issued. <br /> I have and will rTmeokntain watkers'cornpensatian insurance, as required by Section 3700 of the Labor Code, i <br /> for the perfbrmance of" work for which this permit is lssi-ied. My workers'compansation inasl,lrance <br /> starrier and Policy numbers are: <br /> CaltMa. ., 7�►T -- �. __.y . ._ ..�.PoUcy Number: -- <br /> I cerb'1y that in the perforMarice of the work for*high this permlt is 'issued. I shall not employ any person it <br /> arty menri<elr sa as to becarne subject to the workers'compensation laws of Callfbmia, and agree Met if i <br /> Alt Uld bocomo subject to ihs workers compen>sa►1on provisions of,$ectton 3700 of the Latxrr Code, i steak <br /> forthwitri comply with those peavislons <br /> Date: '-/S�O -signaturf, <br /> Printed Name., HCl J .S 159000111 <br /> WAIR)NNG.FAILURE TO SECURE WCRKElRS'COMPENSATION COVERAGE IS UNLAWFUL.AND SMALL SMECT 1 <br /> AN LOAPLOYINQ To CRIMINAL PENALTIES ANC)CIVIL.FINES UP TO ONE HUNDRED THOUSAMID OOLLA►RS <br /> tsi0orS10q,W ADDITION TO 7HE COST OF COMPENSATION,il!�MZ3T, A.i TORNEY FEES, AND DAMAGES R5 <br /> PROVIDED FOR IN SECTION 3709 aF THE LA3CR COOS. <br /> 6!K!—S5 " .--(C-61 licensed authortsrrd mpmoontative),hereby <br /> tar sign this San Joaquin County Well Perrntt Applicatlon on my behalf. 1 ondsrsl rmd*'+'W le vaIA for <br /> one('l)year and is limited to th#mark Flan dated oo the trout page of 00s spplicaatlan. <br /> {Y. <br /> 10 ^� <br />