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.... ( ) L(fJVVz I <br /> San.l4agi ih CaunLy finvironir ee l lia�tith Services,tlhitlliW�I1 P rrl+it.ApP!saatfan,Su a4etnent <br /> JaB ADDRESS: !z. L-JI�111 <br /> PERMIT SL +;l: -- <br /> C 1'1� <br /> LICENSED CONTRACTORS DECLARA4TION (LCD) <br /> I hereby affirm that I am Licensed under the provisicris of chapter 8 (corrimerncing with Section?000}of Division <br /> 3 of the Business and Professions Code and my ii cense is in full.farce and efrect. <br /> /'� Expiration Date: <br /> License#: 7CQV 0 >� <br /> Date: Contractor.' <br /> Signature: Title: i <br /> Printed name; <br /> WORKERS'CC?Rt PENSATIOM DECLARATION <br /> I r)ereby affirm under,penalty of perjury ono of the following declarations: (CHI=CK.i1LL THAT APPLY) <br /> I _I have and will maintain a certificate of consent tc self-insure for workerscompensation,as provided for by <br /> Section 3700 of the Labor Code,for the perforrrianoe of the work for winlch this permit is issued. <br /> ✓ I have and will maintain}markers'cornpensa(ion Insurancc, as required by Section 3700 of the Labor rode; <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers erre: <br /> Policy Number: <br /> C <br /> _1 certify that in the patforrnance,of the work for which this p6i'mit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation lavi<.s of California,and agree•that if I <br /> shouid become subjea to the workers'compensatlon provisions cf Sq4 ion 3700 of the Labor Gode, I shall <br /> forth,4ithccilrnply,with those provisions. <br /> lit <br /> Date: Signature: <br /> on <br /> y Printed Name, <br /> WARNING;FAILURE TO SECURE WOF KERS'COMPENSATION COVERAGE iS UNtAWFUI_AND SHALL SUBJECT <br /> Ali EWIPLOYiiR TO CRIMINAL PENALTIES AND CIViL FiNES UP TO ONE HUMORED Ti•iOUSAND DOLLARS t <br /> IN AQDITIt3N TO TNl:COST OF(,QMpEiNSATION, INTEREST,ATTORNr;Y'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION x706 OF THE LABOR CODE- <br /> I -57}icC+tsei` uthoriz d repiesentative), hereby � <br /> authorize <br /> to sign this San Joaquin County Well Pe Appiic tion►on my 1sehalf, I undY�rstand this authorization:: valid fog <br /> one 1 ear and is tlrnit2d to the work plan dmtad on the front page of this application. <br /> —1�--- } <br /> } <br /> i� <br /> - t <br /> 1,47VS'Gt �66I.–VCS–til <br /> f _ <br /> 1 <br />