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JOB ADDRESS: PERMIT SR#. . Z2353 <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 #: 557 / q 79 Expiration Date: C/ 3? — 2 ciP / <br />A) 5T 6/6 T D1'/i 1' C.),y <br />Signature: Title: Ao.stc-)- 6-F'0 /0 <br />Date: E 3 f;)0 Contractor <br />Printed name: Tr-cr\ C /0 <br />WORKERS' COMPENSATION DECLARATION <br />1 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 />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: Arq tAIV),3 /(15 , Policy Number: v Y6K V 6U 1); 5 4 2 6 <br />Printed Name: limn 71) <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 />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: 0 3-- z-1 soo Signature: <br />I, (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 Klee' VI <br />and is limited to the work plan dated on the front page of this application. <br />vr .