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04/13/2004 TUE 13:33 FAX Z 002 <br /> San doaquln County Envfronmerttal,tieann 5,ervluwr, Unr jV We.It Panmik Apr+liratinn SUDD(ement <br /> , r eReRmm- sE.#s <br /> JOB ADDRESS:_ las 0 I CALt,YX <br /> LICENSED CONTPACTOj2S DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (comrnencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In full force and effect. , <br /> License#: <br /> 7aMAI Expiration Date: 4 1wf/io <br /> � ' <br /> Date: ontractor. <br /> Title: <br /> Signature: <br /> printed name: �� V <br /> WORKERS' COMPE=NSATION 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 /> on 3700 of <br /> he <br /> v I have and for the performanceofof the oain ers'compensat tion insurance, as rk(or which this permit is issued.required My workercompensation it nsuLabor <br /> ran ceCode, <br /> carrier and policy numbers are: <br /> ✓J( <br /> Carrier: <br /> a�Fl�t•1� policy Number: <br /> _I certify that in the performance of the work for which this permit is issued,1 shall not employ any per rson f i In <br /> any manner so as to become subjact to the workers' compensation laws of California, and ag <br /> should become subject to the workers' compensation provisions of S)6tion 3700 of the Labor Code, I shall <br /> forthwi com ly with those provisions. / <br /> (..� Signature: I 1 1�L' F <br /> Date- ` V ' ��`I1 ' ,� <br /> Printed Name:���A.Vk� <br /> AWARNING: FA1LURE TO N EWIPLOYER TO CR MSNAL PENAECURE OLTIES AND CIVIL FIN UP To ONE HUNDREd USANDON COVERAGE IS UNLAWFUL, DDOLLARSUgJECT <br /> ' AN EMDED FOP N SECTION 3706 ADDITIlON TO THE OST EF COMPENSATABOR ION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> (C-57 'ceased authorized raprCsentative), hereby <br /> [to <br /> uthorize <br /> sign this Sa Joaquin County Well P itApplication on my behalf. Iunderstand this autltorfzation is valid for <br /> ne(1) ear and Is limited to the worts plan dated on the front ppage of this application. —_- <br /> - � ' —" <br /> WOLJ� WtrVS Cn l t�6G l–VPI–CI L <br /> 04/13/2004 TUE 14:44 [TX/RX NO 96681 U002 <br />