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JOB ADDRESS C1 741-- V1\, PERMIT SR* .9 O 2.2/2 5 <br />950A - <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br />3 of the Business and Professions Code) and my license is in full force and effect. <br />License #: 7c02_Z Expiration Date: <br />Date: ON OGV 0C Contractor aiNcd.) eci --,1,4/.0/21y)A9 ork\ „Inc, <br />Signature: lily) Title: go,„( Gr pip()) '>--) <br />Printed name: / (N/N Cu <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br />)c,I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />for the performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: f (41-1 Policy Number: ) 3) V 7 ?q <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: 09O Signature: <br />/ <br /> <br />Printed Name: Cu e_ A <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (C-57 license holder), hereby <br />authorize of (consulting), to sign this San <br />Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year <br />and is limited to the work plan dated on the front page of this application.