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JRN 07 2004 4: 11PM HP LRSERJET 3200 P. 1 <br /> 6:/07/2004 :5:58 209-579-' MODESTO ATC P41SE 03 <br /> San Joaquin County Environmental Health Services, Unit IV Wall Permit Application Supplement <br /> JOB ADDRESS:,h�J� C= Lbac b 6 PERMIT SR#: <br /> �.- <br /> LICENSED CONTRACTORS DECLARATION O <br /> 1 hereby affirm that I am licensed under the provis+ors of Chapter 9(Corrmen^Inp with Section 70001 of pivalon <br /> 3 of the Business and Professions Cade and my Ilcense Is in fLN torte and effect. <br /> Llcerise N: 0 "�>� Expirevon Data• �'�b, <br /> Date: Contractor: <br /> Signature: Title: <br /> Printed name <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm unoor penaity of periury one of the following declarations. (CHECK ALL THAT APPLY) <br /> I have and will maintain a certifleate of consent to self-insure for workers' compensation, as previded for by <br /> Section 3700 of the Labor Coda, for the pe^forrnence of the work for which this permit is issued. <br /> I have and will rnaintain workers'compensation Insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit:is Issueo. My workers' compensation insurance <br /> carrier and policy numbers are. <br /> Carrier: Policy Number <br /> certify that ir the performance of the work for which this permit;s issued, 1 shall not employ any person In <br /> any manner se as to become subject to the worKors'coropensatlon laws of California, and agree that if' <br /> should become subject tc the worXers'compensatloi provisions of Section 3+700 of:he Labor Code, I shall <br /> I forthwtth comply with those provisions. <br /> Date: r I�T_Signature; <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPI•NSATION C ERAGe IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINIS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (slao,xo.),IN ADoiTION TO 7F4E COST OF CCMPENSATION,INTERTEST,ATTORNEY'S FEES,AND DAMA13ES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> I. (C-57 licensed authorized nprasentat.va),0.611`412Y. <br /> authorise la's <br /> to sign this San Joaquin County Well Permit Application on my Alf. I understand this suthorl:stlon is valid for <br /> l one(1)year and is Ilmited to the work plan dated on the front page of this appllcstton. <br /> 5-117-2000 1 MI -- <br />