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,05/15/2000 08:21 209468y'^�3 FIFTH FLOOR 46 PAGE 03 <br /> Sari (oaquiiY Courtly:Envlranmental H0.41tkPgryi e$, Umt N IMe111>erm9t lip 0* 9t�pplemenL <br /> Q.. <br /> JQB:AL9fDR5SESS pi'"ITR . <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#: CI''9 %W/-C Expiration Date: <br /> Date: i Contractor: ��ft� a40MOO'c <br /> Signature: <br /> Printed name: •/� �i�uA r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing 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 /> Sedan 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 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: 64M Policy Number: C YYC <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, 1 shall <br /> forthwith comply with those provisions. <br /> Date: I�ZIO Signature: t J/„tea <br /> Printed Name: 4ayo1� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES 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 /> 1 (JJflN /r® /LrtIC� (C-57 licensed authorized representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this ap iication. <br />