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-1 2-200 2,26PM FROM CLARK WELL, INC- 2094625597 P. 1 <br /> 10/10/2000 14:58 209467111 AGE STUCKTON PAGE 01101 <br /> a ti77-1Zi ` <br /> J,r,.4,...r�r......r. .,, M:.' ', ti !! l' • y.kjr <br /> %�" r1•t- '4i. 1v4'l .L'y <br /> , <br /> ,. .: •" .. ., Mµ i.%� ..�r�'.'?' a3:ti'�'r' <br /> LICENSED CONTRACTORS DECLARATIONL(, CD) <br /> I hereby affirm Ohat I am licensed under the proviffiions of Chapter 9(commencing with Section 7000)of Division i <br /> 3 of the Business and Professions Code and my license is in full force and e t. <br /> License if: 1� l / Expiration Date-, c (� C/ Q <br /> Date: !d �� F �CJ GorntractDc <br /> signatui e: <br /> Printed name: /-1 <br /> r <br /> WORKERS'COMPENSATION DECLARA770N <br /> I hereby affirm under penalty of perjury one of the following dedwabons. (CHECK ALL THAT APPLY) <br /> I Have and will maintain a certificate of consent tv self-Insure for workers'compensation,as provided far by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued, <br /> I have and will maintain workers'compensaWn insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit Is issued. My workers'compensaibon insurance <br /> carrier and policy n tubers S are: <br /> �q ` <br /> Carrier_ CV PoKcy Numbet': US6 <br /> 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'oompensation laws of Califforntp, and agree that if t <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cede, 1 shall <br /> forthwith comply with those provisions. � <br /> 01".L O 6 < �L/ Si9naturo., <br /> Printad Name' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (=100,000.),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 (C-37 Au d authorized representative),hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authertiation is valid for <br /> ons 1 and Is limited to the worts plan dated an the Trout pM of this ap0lestiod. <br />