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FicS ri4 <br />10010 <br />PAGE 04 <br />07/10/00 MON 16:45 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />04/28/2000 08:23 2094683433 FIFTH FLOOR <br />San Joaquin -County Environmental 'I•lealth Services; Unit 1V-WPerniitAplicatiOn;'StiiiPlerrient <br />4013:..AribitEss:_ja. : s4..5_ca _l • PERMIT S' <br />AP ),J 2Lict - -1 - z <br />2 t'w9 0 1. 1.3 4,5 4 5 5 4.,Ac4 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby affirm that 1 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 #: 4,s3f.3.5 Expiration Date: _1,3 \ 5_/- O2- <br />Date: -7 -10 -120 Contractor: Fi p lorst- cri, j <br />Signature: Title: (lb) N <br />Printed name: PVtO t IA4 <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 />/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: (0)110 <br /> <br />Policy Number: L53 J05-Q <br /> <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: 710 -CO Signature: <br />Printed Name: <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 />(11 00,000.), IN ADDITION TO THE COST OF COMPENSATION. INTEREST. ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 370S OF THE LABOR CODE. <br />(C-57 licensed authorized representative), hereby <br />authorize <br /> <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work .In dated on the front page of this application. <br />--o <br />41=1=•••..., <br />LO