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04/20/2001 09: 04 209-579625 MODESTO ATC PAGE 02 <br /> Apr 20 01 08t07e ones 5-S1 P, Z <br /> 04/20/7081 BB:52 209-579-2225 Mf7DESTD ATC <br /> PAGE 0: <br /> sen JwquM CetN+ty Envlronmontol Health sarvlaes,U.._.. Wen►arm,APPItirdBUPPle *ret <br /> JOBADDR!89: 1113 SI,FA.../ koI SllIII4_rIa <br /> PE,gA rr bRitt: <br /> LICENSED CONTRACTORS DECLARATION ( ) <br /> 1 Of ebythe affvm that I am licensed Under er+e prOYia.ona Of Chapter 0(commencing with Section 7000)of 0ivieion <br /> 3 M the Buame.e and Professions Code and my Ilcenaa Is n hull force and effect, <br /> License a' EsDirat*n Date: <br /> Dan Q 0dnvatda: �t nVIA r <br /> stpnature: <br /> Title: <br /> Printed Agree: <br /> WORKER!'COMPENSATION OCCLARATION F <br /> I hereby Vfinn under penalty of perjury one Of the following dedareflons: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certili of consent to Nell-"sun for wadersCompaneation, <br /> sechon 9700 of the Labor Code,for as performance of the as provided for 6y <br /> work kr which this permit.a iasued. <br /> �t h"and will maintain workers'comparnalidn Insurance,as required by Section 3700 of Ihs Labor Code. <br /> for the"001 mance of the work for which this permit Is issued. My workers'componsetbn insurance <br /> carrier and policy hujm{pert are. <br /> Carrier:, ( •Ary n Policy NNmpac <br /> 1"'Hilly'hot in the psROrmance of the work for which thls Varma la issued, 1 shall rq!employ any porwn in <br /> e"y manner oro as to become subject to the workara'compen"I Iowa or California,and agree that if I <br /> should become subject to the workers'Compensation INOVIII of Section 3700 of the Labor Coda, 1 7hall <br /> forthwith comply with those provisions. <br /> Data: signature: <br /> PrRlted Nags: <br /> WARNING:FAILURE TO SECURE iNORKeRs'COMPENSATION COW"ADe la VNLAWFUL,AND SMALL 90eJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIFINE$UP TO ONE MVNDREO THOUSAND DOLLARS <br /> 18100,000'),M1 ADDITION TD TME COST OF COMPENSATION,INTEKCVT,ATTORNEY'&FFt3,AND DAMAGES As <br /> PROVIDED MOR IN SECTION 3706 Op THE USSR CODE. <br /> � r" <br /> I. (C-57 Nconead/ilhorf ed nPrasanMtivo),haraby <br /> to of$"tris San Joequtn County Watt Permit Application on my beh&I I understand itds authorization Is Vold A6 <br /> Om(1)y.er end la umllee to the Work plan dared on Ihs drool"goof this egpadaaoe, <br /> Ft 7 S$$p f <br />