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• - <br /> JOB ADDRESS: PERMIT SR#. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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#: 0y �� _ Expiration Date: 11-30 - 00 <br /> Date: - 00 Contractor: 7N G t <br /> Q,� � �_ r <br /> Signature: i!'�"�` _._. Title: 54 a'f (Serol pf sS - <br /> Printed name: a ri M !f�/►sar <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _1 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 /> ,�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: FL,I) Policy Number: (3 <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: �7,"tU Signature: <br /> Printed Name: �rlan ►t!iha*i <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, (C-57 license holder), hereby <br /> authorize of (consulting),to sign this San <br /> Joaquin County Well Permit Application on my 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 />