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F 6 ADPRES8 . PERUAI F SAO M✓+... .41 LICENSED CONTRACTORS DECLARATION (UMJ I hereby affirm that I am licensed under the provisions of Chapter 9(contmendng w8h Section 7000 of Division 3 of the Business and Profes�s7ionns Code)and my license is in full force and effect. License a s� [ 1 Expiration Date: J& 31 0 0 1 Daie'_11/27�Od Cantr7Li r. Signature: r Title: Print* ns rcalifx0 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 try ��Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued. ✓ I have and will maintain workers'wmpencation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued. My workers'compensadon insurance carrier and policy numbers are: Carrier:�lLM/YL�L7td �^t5, Policy Number. Z, cartify 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 California, and agree that B l should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply wlih those provisions. Q Date: 1�/ 2 U Signature: I " Printed Name: _�CcfS �' y WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLDYER 70 CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS (SROVIOED FOR IN SECTION TO THE COST OF 3706 OF THE 1COM ENSAE TERES7,ATTORNEY'S FEES,AND DAMAGES AS I, «,et.— - (C-e7 license holder),hereby authorize or C(U o Q4co Jauidng),to sign:his San Joaquin County Well Permit Appllaation on my behalf. I understand this authorization is velld far one (1)year and is limited to the work plan dated on the front page ofthiu application. i 4