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07/10/00 MON 1. . rAX 1 916 861 0430 <br /> SECOR- SACRAMENTO <br />CD <br /> 011 <br />04/2e/2000 BA:n 2094683433 <br /> FIFTH FLOOR c_PAGE [34 <br />pagein:, litii,t:RW0.1tRe.:7PitAttrilkation, <br />- <br />‘SteiA01;10SS; 23561. 5 Vt. (2-0A-0( : PERMIT R# <br />i b 07 -70 0774-5 <br />zqq, 070 -at( i3 545 S S q bl 23S 5 So.r.4,._ <br />2-Lici-o&5-0tt. z 70i s <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 />5 Expt-ration Date: 0 - - 0 / <br />License #: <br />Date: / <br />Signature-' <br />_J2 <br />Contractor 114)e5 cbrpote-A-A-roi, <br />Re-6 /4W-41-- <br />Cl i-1174-44 Printed na <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 />Xhave 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 arid policy numbers are: <br />Carrier:2-4a Policy Number: <br />/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 4 -//- 0 ° Signature: <br />Printed Name: ,,----72/ e. gm-n.44 A- . 144o, <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 SECT1oN 3706 OF THE LABOR COD <br />(C-57 licensed authorized representative), hereby <br /> <br />authorize '----1-AttIr /4 L') eTL-rrt"LC.,(6 e-c,..ort._ <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this suthonzation is valid for <br />one (1) year and is limited to the work_plan dated on the front page of this ap ication.