Laserfiche WebLink
i <br /> I <br /> In <br /> i <br /> S-, F�,I!*ll <br /> yh�y <br /> CA: �5240 <br /> JJ// a .. <br /> r <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9.(commencing with Section 700t7�)of Division <br /> 3 of the Business and Professions Code and my license h in Ul(once and effect: <br /> UwSg#: 408595 C-57 ExpiraWn Date: 07/01 <br /> We, 6/8/00 Contractor. EARTHY C, LTD. <br /> $ilallllltltl0; �; PRINCIPAL CONSULTANT <br /> Pointed namo: MR. ED HENDR I CK <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the folia declarations; (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self 4noure for workers'compensation,as provided for by i <br /> Section 3700 of the Labor Code,for the performance the work for wh4h this permit is issued. ! <br /> X I have and will maintain workers'compensation insurance, as required by Simon 3700 of the Labor Code,. I <br /> for the performance of the work for which this permit h.Issued. My workers'compensafion insurance <br /> carrier and policy numbers are: <br /> Carrier. ..STATE COMP INSURANCE UND Pou Number: 1353921 <br /> I ceMfy 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 submit to the workers'compensation lows of California,and agree that if t <br /> should become subject to the wotkars'compensation provisions of Section 37DO of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Oahe: 06/08/00 Signature. <4 ! <br /> Printed Nam: MR. ED HENDIR ICK <br /> WARNINt3: FAILURE TO SECURE WORMRRS'COMPl:NSA N COVERAGE IS UNLAWFUL,AND SHALL StJBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1 100,000,).IN ADDITION TO THE COST OF COMPENSAT1001,INTEREST,ATTORNE1r'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370ti OF THE LABOR CODE. <br /> !+ (C-57 licensed auth0rfzbd mpresenteUve�hereby <br /> asuthorize <br /> I <br /> to sign this San Joaquin County Well Permit Appilcartian on iny behalf: I undershind this authorization in vslld for <br /> one 1 year and is Iimited'to the work Vim defied oh the Iran t.paw arthis =won. ,J <br /> Oft 7ClY.IJ .:....� . •:. .� <br />