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Feb 17 00 02: 51p Bre 0ndell <br /> 209-f-8773 p• 2 <br /> JOB ADDRESS: <br /> PERMIT SR*: } G2 (1 �Z <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I 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#:�22G$ <br /> Expiration Date: 04/30/2001 <br /> Date: <br /> Contractor: <br /> Signature: <br /> Printed name: Title: <br /> der <br /> Area 111� <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__ I 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:_S11I1Pri nr <br /> Policy Number: WSN7 9511-A <br /> y I certify that in the performance of the work for which this permit is issued, I shall not employ an <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' p p Y Y Person in <br /> forthwith comply with those provisions. en tion provisions of Section 3700 of the Labor Code, I shall <br /> Date:— -2-17–:0 Signature: <br /> Printed Name: Jim Rlei <br /> lder <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.), 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 /> I <br /> , der nF SPer-trum c• (C-571icense holder), hereby <br /> authorize David POO-leof CH2M Hill <br /> Joaquin County Well Permit Application on my behalf. I understand this authorization is valid tfor)one(1), to sign this San <br /> and is limited to the work plan dated on the front page of this application. ( )Year <br />