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Ess;i 56.15 Sowit‘ AtiAeop. IDOZYPM <br />..* <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />. • t• <br />I hereby affirm that I am IlcanSed under the provons of Chapter 9 (commencing with Section 7000 of Division <br />3 of the Business and Professions Code) and Ty license is In full force and effect. <br />License #: 6 7 Z 0, (3- Expiration Date: . 6 -30 -FW I <br />?ez-Lf-00 Contractor: 11114LXe- 11 br l' I 10,...) c cn r . Ca rio <br />Signature: ,--5— N Title: fiR4 e ati? 7 <br />i_ <br />Printed name: E. 40911 a• ill/ c__Zel/ ale <br />Dale: <br />JUL-25-00 WED 5:24 0 11, D. E. <br />07/24/2000 18:13 20946711i <br />FAX O. 916 852 9535 P. 1 <br />AGE STOCKTCI,I PAGE 03 <br />JAM <br />7st <br />• <br />41. <br />WORKERS' COMPENSATION DECLARATION <br />• <br />thereby affirm under penalty of perjUry';ine•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 />x _ I have end 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: ••••S 6 C.thviliffiSfr Policy Number: 15-e(9,(0-L1 <br />I certify that In tne 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 or the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: 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 10 OWE HUNDRED THOUSAND DOLLARS <br />W00,0004, 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 />Eck4rd /11, 4c_ 41 elf 5e: (C-57 license holder), hereby <br />/ <br />authorize /DM/ r 01 of ALII/Aricei 6e0, 11. (consulting), to sign this San <br />Joaquin county Well.F'qmIlt#PeVatIon on my behalf. I understand this authoriza.tionsi:,71lic ,fa,r one ('l) year <br />111114.41140,1ata1tAnaatip dated on the front page of this application. <br />-41" <br />fDes,c t. <br />(.1 <br />1 <br />-; <br />* . ••41,` '.•... • • ,° j - )1k- j C-s:. 1 k-a- )46 1 ..%. - .t......, : "...