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rrcui 5 e nacnia� rnn Flu. <br /> AGE STOCK•ON PA6E 01/01 <br /> 20946711',_'' � 4 � ] <br /> �•',� Y�i,w .. _ _ .5:.+_ PER SR�. <br /> -7e'a__.: ,'..J: ?.n';'�"•+ - ,.a �. : •t'- ..'. ��'� •''.4 'ry µ r,.�. fitrrr. T • 'SL:-: . <br /> LICENSED CONTRACTORS DECLARATION ( J <br /> I hereby affirm thef I am licensed under the provisions of Chapter 9(oornmencing w4h Section 7000 of DlvtsiOn <br /> 3 at the Business and Profession@ Code)and my license is In full force and effect. <br /> Licen"#: <br /> Expirs0on Dote: Z v a 1 <br /> i - <br /> DOW. g - ��+00 ContraEis <br /> ct r: <br /> ,fviFEC+�- <br /> 5fpn+cttrras: i "Ylde; r <br /> Prints na +ca�.f�•o <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratiana: (CHI=CK ALL THAT APPLY) <br /> I have and will maintain a ceriificste of coni+ont to self-insure fpr workers'compensation, as provided for by s <br /> Section 3700 of the Labor Code,for the perlorrnance of lhrr work for which this permit is issued. <br /> I have and will maintain workers'compenaotioninsurance,as required by Section 3700compensation f the Labor ode, <br /> rm <br /> for the perfoanu of Of Work for whioh this permit <br /> rmit Is issued. M workers <br /> Carrier and poacy numbers are: <br /> r��Zk✓JXttl7►S rP4,s• Policy Number. <br /> Carriarr: _ <br /> mortify that In the performance of the work for which this permit is issued, I shell not employ any person in <br /> any manner so as to became subject to the workers' compensation law$of Csl'rfornia, and agree that if I <br /> should become subject to the workers' compensation provibians of Section 3700 of the Labor Code,t steal! <br /> forthwith comply with those provisions. <br /> Date:` 7 -00 gignatute: xp � <br /> Printed Name: <br /> WARN'INO: FAILURE TO SECURE WORKERS`COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL S1113JECT <br /> Alt EMPLOYER 70 CRIMINAL PENALTIES AND CIVIL FINES UP TG ONE HUNDRED THOUSAND DOI-L4RS <br /> P#t0 ,1+rdD.) FOR INADDITION <br /> TO TH15 COST <br /> SECTION 37�OF THF COMPENSAE .TEiREST,ATTORt4EY'S FEES, AND DAMAGES AS <br /> i1 J r� ASO <br /> (C-57 ikons&hold+ar),hereby <br /> authorho M u r�tM >7 of Q consulting),to sign this San <br /> Joaquin County Well Permit,Appltwtian an my bsh0f. I understand this authorltatlon is vsild far one(1)year <br /> r and is limited to the work plan dared on the front page of this application. <br /> t <br /> 4 <br /> :1 <br />