Laserfiche WebLink
regia UV UV uc: jup arenoa i inues i <br /> w . <br /> ;01r- -6 <br /> JOB ADDRESS: 137-'5' OM 1515- � + Law 4 pE MIT SR#• <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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#: . 512268 Expiration Date: _04/30/2001 <br /> Date: Contractor: <br /> Signature: Title:_ ArpaManaaar, <br /> Printed name: 'T 11, /ri/ai nf P Ider <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 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 /> _x—I have and will maintain workers'compensation Insurance, as required by Section 3700 of the tabor 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, __Superior Policy Number: W N 958—A <br /> _X_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' pen tion provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed Name: Jim Kle' ider <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ° (5100,000.).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 /> I, (C-57 license holder),hereby <br /> authorize_ l"1 —of —�04 (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 Ilmlted to the work plan dated on the front page of this applicatlon. <br />