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Expiration Date: <br />Date: 5 L L-1 <br />Signature: <br />Contractor: <br />License #: 4cs—/&c-- <br />Pa-ri <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />_I have end will maintain a certificate of consent to self-insure for workers compenSation, as provided for <br />by <br />S ction 3700 of the Labor Code, for the performance of the work for Which this permit is issued. <br />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 and policy numbers are: <br />Carrier: PA C'e Policy Number: / G <br />I certify that in the performance of the work for which this permit is issued, I shall net employ any person in <br />any manner so as to become subject to trie workers' compensation laws of California, and agree that if I <br />Should bec4rne subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shah <br />forthwith comply with those provisions. <br />Sig nature: Date: <br />Printed Name: Max <br />WARNING: PAILURE 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 />(siao,00a.), <br />IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATrORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SecrioN 3708 OF THE LABOR CODE. <br />Printed name: <br />ii 't I -1 _(C-57 licenssd authorized representative), hereby <br /> <br />authorize -, I I 041. -a A .. <br />to sign this an JoaquIn County Well Permit Application on my behalf. I understand this authorization is valid tor <br />one (1) ear and is Limited to the work art tiobei on the front e of this a. •Iication. <br />-.IA I 4? f cti <br />`1.1'f BY:. e',g d' rkis ling & Testing, Inc.; 925 313 0302; Mar-15-01 8:39; <br />SECOR- SACRAMENTO <br />0014/2000 12:25 <br /> 2094583433 FIFTH FLOOR <br />Page 1/1 <br />21002 <br />PAGE 04 <br />'CointiptEnvirOniniantaLike.altriSiirvices • pier-T-9 <br />izt -FA-61 t • 1: , • " - DOZ. <br />'! <br />JbADRE <br /> <br /> 'E ' *:17*:$'11 r.:: b 2 - 550 / <br />0 c...V.A.-6Y) <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby efrirrn that I am licensed under the provisions of Chapter 9 (commencing with SeCtion 7000) of Division <br />3 of the Fkisingse and Professions Code and my license is in full force and effect.