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JAMIMRO12:3E L�EST,CE')-ENG.-i•!EGE-S3©-c52-f.i7? <br />San Joaquin CCU <br />i\s, Unit IV Well Parmlt CDon <br />on <br />F.2 _ <br />JOB ADDRESS: - PERMIT SR#t���'4 0 <br />dOozyf�9 <br />- y. uc/ <br />/9 /D Co7e, G4 6 <br />e •� 3/vim <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby aYrm that 1 em licensed under the provsionc of Chapter 9 (comm <br />enClnQ with Section 70U4) of Division <br />3 of the 8'.,slress and Fro'esslons Code and my I'cense Is in fuil force and effect. <br />;License #:.7go4D y- _ ExFiretlon Date. <br />Date: _� a 1Q P Contractor; v� ��.'��� 1 .� c i <br />Signature: 44, Title: <br />lPrin 90 name, -1L <br />i <br />WORKERS' COMPENSATION DECLARATION <br />I i,srsby affirm under penalty of per ury one of t^e fol'.owir.g declarations; (CHECK ALL THAT.APPLY) <br />! I have and will ma!ntaln a cert;flcate of consent to se:f•Insure for v<i�rkers' compensation, as prov dad for by <br />Section 3704 of the Labor Code, for the performance of t.ne work for whlch this permit is issued. <br />ave enc: wlil meinta!n workers' corn pent mlon Insurance, as req,.;Ired by Section 3700 of the ;Labor Code„^, <br />for tho performence of the work For which INS perr-A Is Issued. My workors' compensation insurance <br />carrier and pollcy numbers are; <br />Carrier.• Policy Numbar: " 7/,3 -...5> 33; , - 94 <br />I certify that in the performance of the work for whlc' this permit is issued, I shall not employ any person in <br />any manner so es to become eUbjectto the workers' compensatier. ia•,�'s of CBI&Mle, erd OGree;hat ,f 1 <br />should become subject to the workars' compensation provlslons of Saotlan 3700 of the Leber Code, I shall j <br />foMwlth aornply with these provlslona. I <br />Date: Sltanaturo: <br />Printed Name; L99� — y c,ltCP✓ <br />WARNING: FAOLURE TO SECURE WORKERS' COMPENSATION COVERAOE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPi.OYEFt To CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS i <br />PROVICED, IN ADN ITION TO <br />siort?N THE <br />3708CC+FgT OF LABOR COCEION, INTEREST, ATTORNEY'S FEES, AND CAMAGES AS ` <br />FORI <br />(C•37 tivenxed suthorizad raprasentntivs), hereby <br />authorize <br />to sign this San Joaquin County Well Permit Applicatlon on my behalf, i understand this authoftstion Is valid for <br />one (i) ytor and Is lirnitadio the work plan dated on the front pogo of this appl191tlen. <br />15.17-2000 / MI --- <br />EErESSPM <br />65:3t 22n-/ET/27, <br />12/19/2000 TUE 12:37 1T1/R] XU 671UI 0/002 <br />tM <br />