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JOB ADDRESS! <br />••• 2! ..z,g !7" it."2 1±a—:1. • 's • <br />V;'• • t <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />) otkmit sm: 2'1-59 <br />APR-13-DU FRI 11:16 AM MD, r <br />0010/ 20{rd i7 35 2684671.118 <br />/ 0 <br />FAX NO, 916 P52 9535 <br />AGE STOCKTON <br />P. 1 <br />PAGE 02 <br />I hereby affirm that I am licensed under the previsions of Chapter 9 (corriMenelng with Section 7000 of Divisbn <br />3 of tha Business and Professions Code) and my license is in full force and effect <br />License #: J ri at' / 7--- ExpwationDate:_ 61-- 3 0 - 7-922 <br />otte: Li- -00 contrpoto- Ilf•-d1 bire'11/n ti V , C. 6 gy <br /> <br />Title: 7 74-<,-V, ' deI41 <br />wehrd if;/ 3r. <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarationE (CHECK ALL THAT APPLY) <br />Section 3700 of the Labor Code, for the performance of the work for which this permit is issued <br />have and will maintain a certificate of consent to setf-incura for workers' compensation, as provided for by <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 />cerrisr and policy numbers are: <br />Carrier: 011/14r0;/1-. Policy Number:, N_50---C-(/ 2-C8A- <br />I certify that in the performance of the work for which this Permit is issued, 1 shall not emplby any person in <br />any manner so es to become subject to the workers' compensation laws of California, and nice that it 1 <br />should become subject to the workers' compensation provision Of Section 3700 of the Labor Code, I shaIl <br />forthwith comply with those provisions. <br /> Aita Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUKJEC'r <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANO DOLLARS <br />(6100.0004, 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 />A I ii <br />(A I license holder), hereby <br />atIthorize .gr —I Mill)) cit lice V44 660 fniZigfrY)cltitionsulting). to sion this San <br />Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one 0) year <br />and is limited to the work plan dated on the front page of this spplication. <br />w <br />Signature: <br />Printed name: <br />Date: <br />eN 0 2 2-4 S