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APR--26-00 WED 03 :29 P-•" ENPRQB 1 <br /> 919`5892230 <br /> UP- 02 <br /> E! <br /> 04/26/00 <br /> ,4vEI1 14;50 FAY 209 948 0821 X003 <br /> f <br /> ki <br /> 1 �� :i 'P,ra9i1 <br /> 1 <br /> -'�{'1 I ' ' •'^^'lil"' A1Iry Yf >� <br /> I pl N p YY� �9S ltldPhl �: <br /> i, <br /> lylve� fill Sf <br /> y I� _ ulu b1 _ M1 S <br /> r, n�r �,a. Se T I 1 -4 f '�j� - � <br /> i�''1- i� a�IM s <br /> '�� ,.",�.;' P �if l,y� '<o,''airi;,g„�, pulul11i 14nnum •$�;r:.•:�,slly Nit'. -Ino Illpz.l..ld�. •�- ,.I•�„..a.�,..., n - .. .., . <br /> a:.i �nl,•..:i A...::', ,x'.. --cif',." r_-.'.,. P7..._. .._- ...J. <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 /> Expiration pate' <br /> License#: '+! oda <br /> & Contractor Tide: <br /> Date: . <br /> 1 r <br /> Signature: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following dealarallons: (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 3100 of the Labor Code,for the performance of the work for which this permit is issued. <br /> XI have and will maintain workers'compensation insurance, as requimd by Section 3700 of the Labor Code, <br /> for the performance of the work for which tills permll Is issued, My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier- Palley Number:;. Q <br /> I certify that In the performance of the work for which this permitis issued, l shall not employ any person in <br /> arty manner so as to become subject to the workers' compensation laws of California,and agree that if I <br /> should become subject to the workerscompensation provisions of Section 3700 of the Labor Code, I shall J <br /> forthw;�;. = <br /> ovisions. <br /> i <br /> Date: Signature: <br /> I <br /> Printed Name: i <br /> I <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUEUECT <br /> AN EMPLOYER To CRiNNAL PENALTIES AND CIVIL FINES Up TO ONE HUNDRED THOUSAND DOLLARS <br /> ($10111DED FOR ADDITION <br /> COMP SATION.INTEREST,ATTORNEY'S FEES,ANIS DAMAGES A5 <br /> i —(C-57 Iloahaed authorized represent,ative),hereby <br /> authorise <br /> ko sign this Sari Joaquin County Well Perrnit Application on my behalf. I understand this authorization Is YRlld for <br /> i <br /> nne 1 ear er and is limited to the work tan dated an tyre front z a of thin a liaaticn, <br /> r <br /> I <br /> Pa --ZnHa ?I�10'13 H1�I ££bE99b60Z T£ p� 900Z15L/trD <br />