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-JOB ADDRESS; 1^ 4 <br /> s PE IT <br /> R! S _ <br /> TO <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9(commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code)and my license is in full force and effect <br /> License#: �o�� Expiration Date:��_' 5 '0 <br /> Date: �7'3`}_04( Contractor: ." <br /> Signature: Title: djo <br /> Printed name: f j cc r LYNn <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X' have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: - Policy Number: ( - <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 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: Ti1-01 Signature: <br /> Printed Name: i Ct ri At l ffhoi All <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE.IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO.CRIMINALYP.ENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100;000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (C-57 ticlnse holder), hereby <br /> authorize of <br /> (consulting),to sign this San <br /> Joaquin County Well Permit Application orrmy behalf. I understand this authorization is valid for one(1)year <br /> and is limited to the work plan dated on the front page of this application. <br /> i - <br /> F <br />