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z <br />4, <br />u). r � : ::�[ i',..• . '^:-; :�ri;;,F.3G✓:.:� �',i:r �^. ;r.�� �..:(1°�n ^.^...::,.'� •'". <br />,nnoIFCA�. ��GS t.)• )l"",`itiar�.t _--pEl'tN11T�:3i'k: oo2ySyg <br />LICENSED CONTRACTORS DECLARATION W= <br />I hereby affirm that I am lloenaed under the provlslorw 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 Rffect. <br />11 <br />Ut*W* 5fN-]J E>cpiratton Data: G ..._--.._.— •— <br />Printed name: <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 cerffmoie of concent to self -insure for workers' compensation, aS provided for by <br />Section 3700 of the Labor Cade, for the performance of the work for which this permit is issued. <br />V 1 have and will maintain workers' compensation insurance, as required by Section 37do of the Labor Code, <br />for tl*parfermance of the work for which this permit IS issued. My workara' Compensation insurance <br />carrier and policy numbers are: <br />Carrier: ytp 14 C t) Policy Number. ��,� <br />r l comity that In the performanca 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 aub)oct to Via workers' compensation provisions of Section 370D of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date:., Signature: �! t- C �-- <br />Printed Name! <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENA6TIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(S7OD,DDD.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE, <br />e-14 47%-4 me-J?42Jr7/1� (C47 ticenea holder), hereby <br />authorise rG4 '�A�� of AIy- 6 0 ..__(consulting). to sigh this San <br />Joaquin County Well Permit APOIC■den en my behalf. I understand this authorization is valid for one (f) year <br />and Is limned to the work pian dated on the front page of this application. <br />CO 39Vd NDiADO1S 39V 8TT1L9689Z TE:LT 990Z/t7T/TT <br />