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t✓ <br /> :;+a:�= .i,''�::,.r .fes'-'-:fir- -"r._- '.1`"t•^i -- _ x.lr:..' ^''y"•L„ ��_�s.•' � .- - <br /> -:M`'a'. ., _�' _ �.�.I�-.��T�,:,T�•.-�:. . ._ _ Y...� :c.s^.i•iri�-S•�!r'�'C.Y:_ _�''w..•. <br /> 'JOB AWRESSr�'L � �YAE_RMf`i` - <br /> _ 7'+� <br /> hy, - 'yri�:�:n'�C� -M�`-..]r '�-=.+ - +.'�R_�...i L�iolRr-�: t'6'^�:'A�:- ��i�:.Zwr•'. .i <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the prnvWons of Chapter 9(commencing with.Section 7000 of Division <br /> 3 of the Business and Professions Code)and my Ilcanse is in full force and of ecL <br /> z o � <br /> ..�� ? �itatton Date: �h� 3 f v <br /> Lleensle#' -� _- <br /> Date:_ <br /> 16>1p <br /> D 6 Contract <br /> SFpntrture: 'Tidr-7 <br /> e:•-- ���� <br /> Prints na ic1�.rRa <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarafiant;: (CHECK ALL THAT APPLY) <br /> I have and will maintain a cerffic3le of consent to self-Insure for workers'=mpensation, as provided for by <br /> /Section 37DO of the Labor Coda,for the performance of ft work for which this permit is issued, <br /> �f 1 have end will maintain workers'compensation insurance, as required by Sedlon 3700 of the labor Godo, <br /> for the performance of the wr}rk Icr which this permit is issued. My workers'compensation Insurance <br /> carrier and policy numbtra are: <br /> Carritlr:�r� S 5 r:j4 ' Polley Number +v �$( <br /> ZI 00nify that in the performance of the work for which this perms€)s Issued, I Shelf not employ any person In <br /> any manner so as to become subject lo the workers'compensaflon laws of California, and agree that W 1 <br /> should become Subject to the workers'compensation provisions of Section 3700 of the tabor Code,I shall <br /> forthwith comply wAti-those provisions. <br /> Date: 1G y3 S1Qnatuta: (.[ <br /> Printed Name: <br /> WARNMIG: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES Up TO ONE SVNDRED THOUSAND DOLLARS <br /> (S1t)D,OGO.), IN.ADDITION TO THE COST OF COMPENSA TEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> i'1 Oyfl)ft POR Its SECTION 3709 OF'THE LASO E. <br /> 1, 1 fC-67liccnse holder);,hareby <br /> authorfsa cf d' o Q�eo�ultingl,to sign this San <br /> Joaquin County Well Permit Application on my bohslf. I understand this authorization is valid for ons(t)Year <br /> and is limited to the work plan dated on the front page of osis application. <br /> l� <br />