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07/09/2003 12:34 209-579-2225 MiODESTO A7C PAGE 83 <br /> San Joaquin :ounty Environmental Health Services,Unit iV Well Permit Applicatlon Supplement <br /> JOB ,DORESS. Z M,041-- LJW 9- 1 PERMIT SR# : <br /> LICENSE® CONTRACTOIS DECLARATION <br /> I hereby affirm that I am licensed under the provlsions of Chapter 9 (commencing with Section 7000)of Divisian <br /> 3 of the Business and professions Code and my license is in full force and effect. <br /> License Y9 2 Expiration date: l 6xe za <br /> Date: 7 z-,�D5. Contractor. <br /> Signature: Titlal:.,. <br /> Printed name. <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY <br /> have and will maintain a certificate of consent to self insure for workers'compensation,as provided for by <br /> Se <br /> e:tian 3700 of the Labor Code,for the performance of the worm for which this permit Is issued. <br /> have and will maintain workers'compensation Insurance,as required by Section 3700 of the.Labor Code, <br /> for the performance of the work for whicn this permit is Issued My workers'compensation insurancs <br /> canier and policy nurnbtm are: <br /> Carrier: a1422 Policy Number. l' <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 es to become subject to the workers'compensation laws of caitfamia, and agrees that If I <br /> should become s;jbjeci to the workers'compansation provisions of Section 3700 of the Labor Code, I shell <br /> forthwith comply with those anavisions, <br /> Date: 7o' Signature: <br /> Printed Mame: C!� <br /> WARMNO; FAILURE TO SECURE VVOR"RS'CCMPENSATI®N COVERAGE IS UNLAWFUL,AND SHALL 3UBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CrAL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($10DE <br /> 0, D FOR IN SECTION}T9 COST Or- <br /> Tii1:1-AI3OR CODTION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> pRov (C-3T licensed authodrad repm"ntatIve),hereby <br /> autfeorize <br /> to sign this San.soaquin County Weil Permit Application on my behalf. t understand this authortratiort is valid for <br /> one(1)year and Is limited to the workplan dated an the front Page,of this application- <br /> SAT-2000 r MI <br /> E'd 0006 13CN3SH1 dH WdSbet 6002 so -inc <br />