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T r..:J:-Y'',,• . ::'.'.(: -�+. rt �Y�ti i'1•'b - y',j"'4 �::r•n.' I:f • ^,y��Vl `(.., <br /> ' � -- •,.'.. .:. •, •;�•^.. ,{+.rte .« . L,14'Y4'• "'�'• tir.. <br /> ;>loe ADORE59. = ��- PE MM SR*: <br /> "•1Y1'TY. <br /> w��c •�..^: .... -Y '�;�'•... ....�::Csi:��"���" '�.',.:�5�`'r =�•'•.;,'_ ' <br /> LICENSED CONTRACTORS DECLARATION (LC <br /> 1 hereby affirm that I arts Licensed under tho provisions of Chapter (corrInvImcing with Section 7000 of Divislion <br /> 3 of the Sualneassa'nd Prooffelssions Code)and my 1"nse is in tug f rce and effect <br /> License t 1 C� - _Expiration Dat : _ o <br /> Dine: Con LW ' <br /> signature! Lc Ile: �l <br /> Printed name., Gl <br /> WORKERS' COMPENSATION GECLARATION <br /> I hareby affirm under penefty of perjury one of tf)e fallowing declar Hens: (CHECK ALL THAT APPLY) <br /> I have and will ,"intein z cerYicaie of consent to self-insure f r workers'con;�penaetion, as provided for by <br /> ��Section 3700 of the Labor Code, for the perforrrance of the w rk for which this permit is issued. <br /> �' 1 have and will maintain workers'componsatio;;in vmnce, as required by Section 3760 of the Labor Code, <br /> for the performance of the worts for which this permit is issued My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: ! t 05 de C t _ Policy Numbber. U <br /> I certify that in the pe'(ormsnce 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' comperilation taws of California, and agree that if I <br /> should become sub)ect to the workers`compe~setion provisions of Section 3700 of the tabor Code, I shall <br /> forthwith comply with those prcvisloria. - <br /> Date: Jr 7- zcao vSi9nattrra: r <br /> Printed Mame,. <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL$VOJECT <br /> AN t`WPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (SIOO;DDD.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST.ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 of THE LABOR CODE, <br /> l r crl.k'r�+o �-C•2�L/�Y�� (C-57 license holder),herolay <br /> suLhori2e �4-t ' tL� of Ao,✓ e-ro (consuWng)i to sign this Son <br /> J"quin County Well Permit Application on my hahz1f. I understand this svthRrizztion is valid for one(t)year <br /> and is limited to the worts plan dated on the pont page of WS 2pplicsVOM. <br />