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JOB ADDRESS: PERMIT SR#: <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 #: (o7 n Expiration Date: 6 - 30 -- <br />Date: 3 - 9 - 00 Contractor: /14 lirdn e(I Ef\t,i'fo 2 a tkNe rifet, <br />Signature: 2//.1-6,--. An.,(1 tinan EaClol? i e A'l 1-1-6,eti Title: Pio in ci7 e <br />r M )1A:lan •r/1 tdoht if4 4-e-te () <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 />y 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: 40A-e. Policy Number: 1311 7 - 9 <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: —0C) Signature: <br />Printed Name: c)) le( in All ) 1 Mai) <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 /> <br />EJ ,AA c-;-dA-e II <br />authorize ictn / (HA-10,K? of <br /> <br />(C-57 license holder), hereby <br />(consulting), to sign this San <br /> <br />AcF <br /> <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. <br />Printed name: