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CatIA1042 <br />17dB: ,A0REsz: Lltic6 Po Li lc; i'A'7-yERhfin- SRI*: 6d2-(07-e5 <br />. • $an ,Joaquin t.'.cunty invIrcornental lisaith Serv1cas, Unit IV Wed- ?err:lit Appikation Suppierne:74 — <br />JAI/11 <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I !-..erey affitrrn that i am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Gusiness and Professions Code and my license is in full force and effect. <br />License it LI, .--L.0 401 Expiration Date: iit'D/ /o- <br />Date; 5124--) _p Contractor: <br />Signature: bt)LOSL,-- litie: <br />Printed name: <br />WO KERS' 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 />%/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: Maftg,... it--sPaill Ls"... Policy Number: LOC, t - is— ft". <br />t3 <br />'--60 <br />I certify that in the performance of the work for which this permit is Issued, i shalt 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 37JX Of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: -740 t <br /> 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 />($1(70,000.), IN ADDMON TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />marzi (C-57 licensed authorized representative), hereby <br />authorize j r Ii - II L '•'1,Iii <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authortzatIon Is valid for <br />one (1) year and la limited to the work plan dated on the front page of this application. <br />5-17-2000 / MI <br />Wcufietit <br />rrafta