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`r/ <br /> 11/30/2004 09: 50 209-579-2225 MODESTO ATC PA'=E 04 <br /> San Joaquin County Environmental Health GeParbrte <br /> nt Unit N Wen Pemeit Applkation Supplement <br /> JOB ADDREl <br /> SS: 'S �� PERMIT SRlR: <br /> LICENSED C <br /> pWRACTORS DECLARATION LCD <br /> I hereby <br /> affirm that I am licensed under the provisions of Chapter 9(Commencing with Section 7000)of Dnnsron I <br /> 3 of the Business and Professions Cade and my Itcanse is in toil tares ands ecL <br /> /�//d <br /> License#; �J d�~i `•S�7 Expiration Date: <br /> 3 b��_Contractor ,�„[,t.d/ <br /> oat.: J..�_--_ 7r«c. no U f <br /> Signature• TPW . ••••, <br /> Printed name: <br /> WORKERS,COMPENSATION DECLARATION <br /> hereby affirm under penalty of pequry one of the foilawang dwUrattOne' (CHECK ONE) <br /> _1 have and Wi ;nsintain a certificate of consent to sW4nsun for workers'compensation,as provI for <br /> rformsnes of the wont for which this permit is issued. <br /> by Section 3700 of the Labor Code,for the pe <br /> _I have and will mairein workers'compensation Insurance.as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this penult is issued. My workers'compensation insurance <br /> carrier and policy numbers are: 1 <br /> Carrier: tF �ll✓t n Policy Number: <br /> I certify that in the performance of the work for which this permit is Issued,I shell not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: //z-4T/f'! Slgraturs: _C.zd AAS <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=100,400.),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAG FS AS ` <br /> PROVIDED FOR IN SECTION 3706 OF THE LASOR CODE. <br /> AUTHORIZATION FOR QTNER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, On t r� L�=W ¢D (aignsturs oC-fn licensed authorized reprosantative), <br /> hereby surd ilte(pane name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this suthorW tion Is valla for <br /> one(1)year and is limited to the work plan dated on the font pope of this application. <br /> 8.29-02/Mi <br /> nouf SuTITT.ra pa9Mp00M 00£6t+L£L04 XdcI 6£:60 6007./0£/TT <br />