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10/04/2004 15:23 209-579-2225 MODESTO ATC PAGE 02 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOB ADORESS:7A7t & W'*9Z -��� PERMIT SRS: <br /> LICENSED CONTRACTORS QECLARAMNL{ CDl <br /> I hereby affirm that I am licensed under the provisions of Chaptar 8(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my licansa Is In full force and eff ct. <br /> License N: <br /> `71 00 747' Expiration Dan: <br /> Date: d l d i� Contractor: +CJ w A12 D 2/ i✓6 CO r <br /> signature: czja� Tltie:• <br /> Printed name: GUn/Gi Aja c.✓ o o Dla./r4 R <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by <br /> �on 3700 of the Labor Code,for the performance of the work for which this permit is Issued. <br /> _I have and will rnaintain workers'compensedon Insurance, as required by Section 3700 of the L.2bor Code, <br /> for the performance of the work for which this permit'is issued. My worker's'compensation Inaurarice <br /> carrier and policy numbers are: <br /> Carrier: _ 5 77&*l x74 v D Policy Number, a ° k O- 3 <br /> I csrtlfy that in the performance of the work for which this permit Is Issued, I shall not employ any person In <br /> any manner so so to become subject to the workarV compensation laws of 04411bri llo,and agree that If I <br /> should become subject to the workers'compensation pmlalona of Section 3700 of the Labor Ccde, I shell <br /> forthwith oompiy with those pravislons. <br /> pate: /0) ,y a 4/ Signature: - <br /> Printed Name: C o rJ G�.�► E !/lJ c� n W14 2�_ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION CMRAG!iS UNLAWFUL,AND SHALL SUBJFCT <br /> AN SMPLOYtI R TO CRIMINAL PENALTIES AND CML FINI$UP To CNN HUNDRED THOUSAND DOLLARS <br /> PROVtOED OR IN sEoN To 97tH O!ST O Cleo',ENSACODON.IMREST.ATTORNEY'S FEES,AND DAMAGES As <br /> I, (�t./p^�—�c•✓c..�.1 (G57 licensed suthoMssd rsprM•ntative),hereby <br /> authorise <br /> to sign this San Joaquin County Well Permit Appllaation on my tnehaN. 1 understand this outhOM28tton Is valid for <br /> one(1)year and Is limited to the work plain dated an the front page of this application. <br /> .Z I <br /> E00Q!1 auTTTTJG PJvAPooM "00£6t4£LOL XVA LT:9T t00Z/£0/TO <br />