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03/02/20x4 14:07 209-579--2225 MODESTO ATC PAGE 03 <br /> San Joaquin County Environmental Health Services,Urtiit IV Well Permit Application Supplament <br /> JOB ADDRESS: ri qqs N �� PERMIT SR#: <br /> S L <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affm'n triv I am licensed under the provismns of Chapter 9 (commencing with Section 7000) of Division <br /> 3 of the Susiness andPr7ofessiion�s Cade and my license is in Ul force and effect, <br /> � <br /> license , ,I r,)i��7(D`tV-7 Expiratlen Date: <br /> Date: Contractor: _ _ <br /> Title: <br /> Signature: ? � �( '��� �t J��IU <br /> "cited name: �7 L <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penatty of periury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a cortificate of consent to self-insure for workers'compensation, es provided for by <br /> Sectior 3.700 of the tabor Code,for the performance of the work,for which this permit 1s iasued, <br /> I hays and will maintem workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> Tor the performance of the work for which this permit is issued. My workers' compensatlon insurance <br /> carrier and policy numbers are: <br /> Carrier: ��l 1 1l S Pollcy Number: �yi U✓l j - <br /> I certify that in the performance of the worK for which this permit is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of CatlY'amia, and agree that if I <br /> should becorne subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with thff ase provisions. <br /> Oats: 3lft2.UyJ Signature, <br /> Printed Name: �' ✓ <br /> WARNING- FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE I$UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDREC THOUSAND DOLLARS <br /> (3100,1500.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3,ad OF THE LIBOR CODE. <br /> II � <br /> I, V� (C-37 licensed authorised rep rosenEadve),hereby <br /> auth*f12& <br /> to mifln lhla San Joaquin County Well Permit Application on my behal I understand thin authorization Is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> 9-t7-200!5/Ml <br /> C -d SILSETE906 uaplen R.aew d1s : I0 b0 20 Jew <br />