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<br />07/11/00 TUE 10:33 FAX 1 916 861 0430 SECOR-SACRAMENTO <br />FROM kle#t Ra."1. , FAX NO. : 1916638E613 <br /> <br />07/10/00 01,1108 FAX 1 916 861 0430 SECOR- SACRAMENTO <br /> <br />g4/28/21308 0t3723 2E194682433 I IT TH F11OR <br />:,:giiiii:4444,,,d„,0460y:E.i.iyirertmen41410attft fereilCrie;Lififflitfer.17iFal.106611741401447141n <br />.11.0•11.01? a.:IS;• 23 l5.5.0,;;06,•,,,Vy_ R4, ' 1;0iift Mi iit'.5 t,. — . <br />' • ' - .A.Rw-, '..'" ' _ - ----._ <br />1-. id:Ci . <br />Fr <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby athrm Mat I rim licensed under the provisions of Chapter 0 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my license is In full force 2nd effect. <br />License #: 5 S 4-/ 47 t.7._ Exphtion Date: 01 3Lr .O / <br />Date: - I - Contiactor: <br />Tide: X4flb/o44.4,41_ 1.14A-?-4,.f6t <br />Printed na <br />WORKERS COMPENSATION DECLARATION <br />hereby affirm under penalty of penury one of the following declarations. (CHECK ALL THAT APPLY) <br />have and will Maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br />Seceon 3700 of the Labor Code. for the performance of the work for which this permit is issued. <br />and will melntein workers' compentietion insurance. as required by Section 3700 of the Labor Cade, <br />for the performance of the work for whidi this permit is lesusd, My workers' compensation insurance <br />carrier and policy numbers are: <br />__X <br />Carrier. / Policy Number: fit kii5/14/4 itrLf o <br />certify that In the performance of the work for which this permit is is.sued, I shall not employ any person In <br />any manner so as to become subject to the workers' cOmponsation luvirs of CSIMMia, and agree that Ill <br />should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shell <br />forthwith comply with 1110se provisions. <br />Dare: 4-/1- 6 E3 Sig natUre: <br /> <br />Printed Name: 2I c4-tpi. <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 15 UNLAWFUL, ANU SHALL SUf3JECY <br />AN EMPLOYER TO CRUANAL PENAL1159 AND CML FINES UP TO ONE HUNDRED THOUSAND DOI.LARS <br />(s100.noo.), IN ADDITION TO THE COST OF COMPENSATION. INTEREST, ATTORNEY'S FEES. ANL) DAMAGES AS <br />pnoviDED Fon IN secTioN 370 OF THE LABOR CO <br />(C-Sr licensed authorized ropresontOtiVe). hereby <br />I.orlae ,Aawels- t.J ca4-7/41- <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valld for <br />one 1) ear ari51.# lirrilted IQ the 2r1cjlnd of this applicAtion. <br />Signature i C, 6- <br />Jul. 11 2000 07: 44AM P2 <br />[al 014 <br />PAGE El4 <br />[ZI 0