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04/x5/2000 16:10 2694671118 AGE S OCKTON �� r <br /> PERl1Oli`f�' . <br /> 'JOB A©DRESS v( *- :r ,> _• Y,SRafE:' <br /> e7- �•._• -__ S ,HT 4�._ -�•4~�1� .,.. hC2r,'•-r �i�._tir u�{L. .�. yw-_+: T _ 75 .i <br /> 'iS.Z i=����5.-�.3�� iK�'_.-M �'�..I•v~.r"_ "MK�M'�*. .:���'.�.._: :�� lam•' ..'J:�� <br /> LICENSED CONTRACTORS DECLARATION (LCD1 <br /> I hereby affirm that I am licensed under the provisions of Chapler 9(oommenOng with S*atian 7000 of Dh►Ma1on <br /> 3 of the Business and Professions Code)and my Iicanse is in full force and effeCL <br /> Uicensrr it Expinstlon Date: J fr,4 1 pa <br /> Date.� � -�6 0 � Contract r: <br /> Arinte na • fcif t�0 <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of.the following deciarationa: (CHECK ALL THAT APPLY) <br /> I have and will maintain a cerfficate of canoont to seif`insure for worksrs'compensailon, as provided for by <br /> ��SeOon 37 D0 of the Laker Code,for the performance of the work for which this permit is issued. <br /> ✓ 1 have end will maintain workers'compensation insurance,as required by Secilon 3700 of the Labor 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 /> Ca►rlrr: tLz s r+45• Policy Number., <br /> ZI carlffy that in the perfflrmance of the work for which this permh is Issued, I shall not employ any person In <br /> any manner so as to become subject to the workers' compensation laws of Caiitornis, and agree that if I <br /> should become sur}}ed to the workers' compensation provisions of Section 3700 of the Labor Code, I &hall <br /> forthwith comply whn'those provisions. <br /> Date: r 'orb 6 Signature. <br /> Printed Name: <br /> WAAWNG: FAILURE SO SE=CURE WORKERS'COMPE=NSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CfVIL FINES U?TO ONE HUNDRED THOUSAND DOLLARS <br /> P J00,,D7EO FOR ADDITION TO THE COST N SECTION 37 BOF THE CO777:71C-57 <br /> ASO 'S FEES,AND DAMAGES AS <br /> license holden,hereby <br /> authortsf of + a Q con evildn9j.to sign this San <br /> Joaquln County Well permit Application on my baNIf. 1 understand this authorization is voild for one(1)year <br /> and is limited to the work plan duffed on tho front page of this application. <br />