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09/19 2081 09:48 7073745x, j s IDWARD DRILLI�O PAGE 03 <br /> ft t /2081 11:4a 209-b7g-�'*..} MODESTO Am PAGE 83 <br /> San Joaquin County>envirenmental Hsskh 5eervkflis, Unit N Well 106aWt Appliawdon Supplement <br /> JOB ADDRESS 373 ERMIT <br /> r LICENSED CONTRACTORS DECLARATION (�} <br /> t neraby•ltirrn that I am itcoMed under the provitinne.of Chapter S(cormmenChV with Section 7000)of Dlvtsion <br /> 3 of the Businsse and Profeaskm Code and my License is In fud force and effeaL <br /> License#: 5 7 1* Evinition dati: " f• <br /> Date: jT-I • 01 ---- tractor: <br /> 23lgnfffoba : Tlti•:� TJIf�M'S, A�u <br /> WORKERS` COMPENSATION DECLARATION <br /> I hemby affirm Under penalty of p"ury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and w4l malateirt a coMicate of conser:t to self-inure for Wn&Ws'rwt"rs*dm.a•pmvkbd for by <br /> Sectim.3700 of the LOW Code, for the performance of the work br which WS pwmg Is ieaod, <br /> i have and WM rMaintain workers'compensation iruura nce,as required by Stdon 3700 of dw Labor Code, <br /> for the pe17onnareoe of the work for which this perrml Is Issued. My workers'compensadon Infwrance <br /> colow and Policy numbers aro: <br /> Carrier; tA'1r , -.------_-- --- --Poncy Number. als <br /> i comity that in the performanea of the work far which this permit is lseuee#. 1 shag nal employ any Person In <br /> Any marw w so as to became subject to the woftfs'a mp•n•ation low of C•lilbrreit,and aqm dW S I <br /> should boom*amiod to me workers'compsnsado n provisions of SecW 3700 Of tte!Labor Code,t:hall <br /> forthwith oomph'with erose pmvislons. <br /> Dale: ? /�''�I alone ' <br /> Printed Name: <br /> wAFwNG: FAILURE Tb SSCUI9 fA ORKSAW COMPVISATWN COY ItAGN It UNLAWFUL,AND SMALL SULIECT <br /> AH'E11rPL0YVFk TO CPJMINAL PENALTIES ANO CIVIL FMS UP TO ONE HUNDRED THOUSAND COLL4AS <br /> (Slaps?,IN ADDIT10N TO THE 0067 OF COMPENSAMN,INTERE3T,AMANeIrS MS.AND DAMAGES A3 <br /> PROMED FOR 114 80C'f10N 37oE Of THE LABOR CODE. <br /> L 644 C2611 Tom► _ —(0-37 etasrared outhartsed reprsaentsttve),hereby <br /> ouv*Aw r f0&-" COAjur-0-Agto si#n elle Un,laaqufn County WNe PartHt Appileaetlen on my behalf. I understand this author eadwi Is valid for <br /> dno(f)year and Is limited to the mark pian dated on the front page of this application. <br /> •1 C#Ai <br />