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SanJoaquinCourity.E641Fohmental"He®ttN3oniiees,,Diik'.IV!INe1t;PetmiC7Fpp11CaYlon Supplemerrt JOB ADDRESS: .11 .7 o r►m t321 f2c,G ST•eccr PFAiurtT $a#:1�l�2 LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with Section 7000)of Division 3 of the Business and Professions Code and my license is In full force and effect, License / DU 7 q Expiration Date: O7- c3 I � !r7 Date' 1 /00 Contractor OOOCO CO f�-De1",4 rJG� 77 i& Signature: - S 002__Z d-� Title: Pw- •-� Printed name: e'o tiG/n/ e- 6L- Gl�l� t.J i9-/e WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate of consent to seWinsure for workers' compensation, as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: carrier: 62ZZ. Q nJ_.L- _ Policy Number: _ I certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if I ! should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. r Date: Signature:— Printed Name: — -- --- WARNING: FAILURE TO SECURE WORKERS'COUPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100, ADDITION H B OFTHE SF COMP CODE.ON,INTEREST.ATTORNEY'S FEES,AND DAMAGES AS DED FOR IN SECTION 3 S7 licensed authorized repmsentative),hereby authorize 1 K 4� �d to sign this San Joaquin County Well Permit Application on my behalf, I understand this authorization is valid for. one (1)year and Is Hmked to the work plan dated on the front Pageof this epplicetion.