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-..103 ADDRESS: S < () 352-4, <br />., <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 end Professions Code) and my license is in full force and effect. <br />License #: (9--2&/ Expiration Date: 6 - 3C--- ZeO 1 <br />Date: 7-471- 0 Contractor: I )Id i/J/,jcç Cnv Co,, <br />Signature: # • 4141( Al 4.7 aim <br />/ <br />Printed niime: kind /11, A1/17 " <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 b issued. <br />X 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 OM policy numbers are: <br />Carrier: S thi) Policy Number: I 5- (.9 <br />car* that in the performance of the work for which this permit is issued, I shell riot employ any person In <br />any manner so as to become subject to the workers' compensation laws of California, and agree that if <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: Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVOtACE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP 10 ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S PEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />1 N4-14 /W., 441.+C.4e 0 .3-A (C57 license holder), hereby <br />authorize /Orly /141'citic , cli of Agviweril 6'eo , Cnv, (consuming), to sign this San <br />Joaquin county Well Permit Application on my behalf. I understand this a ulhOrItAtIon Is vellel for one (1) year <br />end is limited to the work plen dated on the front page of this applimation. <br />ilf -e+5 -1-- <br />JUL-24-00 TUE 1:15 PM M.D. E <br /> <br />FAX NO, 916 P;'. 9535 <br /> <br />P. 1 <br />07/24/2000 10:13 2094671—d AGE STOCKTON Pkg3E 02 <br />SR obz_3sz