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07/10/00 MON 16:45 FAX 1 016 861 0430 SECOR-SACRAMENTO Z010 04/20/2000 06:23 2094688433• FIFTH•FLOOR • PAGE 04 ic�Tior►SpppldmWtt. San Jeaquin:Ctrpnty;Erivironmenfgl'FI'a "CY ~- vt ,aFmss: A..os1 Z�19:U70-oIZ z3ih�3':s..:ta, >=c-it,�, . . _ . -... - • 2'14-07t7- Oto 2345A s 5a 6 fe load LICENSED CONTRACTORS DECLARATION (LCD,) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7D00)of Division 3 Of the Business and Professions Code and my license is in full force and effect. License#: (0913865 ExprrationDate: Date: 7-to-00 `Contractor: F-QL , t hU,rw YrtCn�ti1 tXP lora�ib $eV✓lir Signature: f �/ �L /' Title: Q()NP tf- Printed name: AVl FrSu+ WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) _I have and will maintain a certificate of consent to self insure for workers'compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance,as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers'compensation insurance carrier and policy numbers are Carrier: .•5444 l��K� Policy Number: �.�1aa05 �5 _I certify that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers'compensation laws of Califomia, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. p Date: 7-/6 -04 signature: Printed Name: JIB /1 Srad WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLSUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS (§100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. I,_ ,/// V)o -(C-67licensedauthorized representative), hereby authorize to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(1)year and is limited to the VMrk plan dated on the front page of this application.