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t <br /> JOB ADDRESS: PERMIT SR##: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business and Professions Code) and my license is in full force and effect. <br /> License #: (o"] ado Expiir"ation Date:: 6 D U <br /> Date: 3 - Cj -DU Contractor: �� 1Le td f I �,'�9 n>,rfoYl .Me�+'��1 <br /> Signature: �4� / t(( e ��4Cf4ll Title: Li0of✓' <br /> Printed name: r �� f✓� l nk'A,q 4,1 �r/d 1 ,lam i ! <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby a`arm 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: 4-�cz-tr� �vy1(,Q Policy Number: LI-7 — 97J <br /> I certify that in the 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 of the Labor Code, I shall <br /> forthwith comply with those previsions. <br /> Date: S ' f 5 Oct Signature: <br /> Printed Name: �f 1011 <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 /> (S100,000.), 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 /> a, L (C-57 license holder), hereby <br /> authorize I ic',P1 / I�I��� of A. (consulting), to sign this San <br /> Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year <br /> and is limited to the work plan dated on the front page of this application. <br />