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S JAMI@IqO ruin €" aunty Environmental Health Department Unit IVP ESS: t App►Icafi Su a p 1 d. ppleme, PERMIT SR#:--' odd wj LICENSED CONTRACTORS DECLARATION (LCD) +rm +hat I dm licensed under the provisions of Chapter iusmess and Professions Code and m I� f 9 (commencing with Section 7000) of Divisic; .� y 'cense is in full force and effect. ^4p �. Expiration Date: t Z r o Contractor: e. O Title: j!' 7P, WORKERS' COMPENSATION DECLARATION Y of perjury one of the following declarations: (CHECK ONE) 'v'+'t m,,intain a certificate of consent to self -insure for workers' of the Labor Code, for the performance of the work for which this nsation, as provided for Maintain workers' compensation insurance, as required b Sec • permit is issued. lce of the work for which this permit a issued. M •r numbers are: y tion 3700 of the Labor Code, MY workers' compensation insurance Policy Number: /3 o _ w ghat ;n the performance of the work for which this / > 4tariper ^,c, as to become subject to the workers' compensation subject to the workers'co permit is issued, I shall not employ an h laws of California, and agree that iperson in Amply with those provisions, pensation provisions of Section 3700 of the Labor Code, I shat Signature: Printed Name: TO SECURE WORKERS' COMPENSATION COVERAGE IS CRIMINAL PENALTIES AND CIVIL FINES UP TO O '_ tTION TO THE COST OF COMPENSATION, INTEREST, HUNDRED D THOUS, AND SHALL SUBJECT .N SECTION HE OF THE LABOR CODE. ONE HUNDRED THOUSAND DOLLARS S FEES, AND DAMAGES AS 111 ',0ZATION FOR OTHER THAN C-57 SIG NTNG PERMIT APPLICATIO 1� � N (signature ofC-57 licensed authorized repr - _rrinf name)_<,- �p esentative), � sari :104i,uin County Well permit Application on m y behalf. end is limited to the work plan dated on the front page of this understand this authorization is valid for �! is application.