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FIFTH FLOOR PAGE e3 <br /> ,05/15/2006 08:21 209468 „433 • <br /> uih Courify:t=rrvlra!mentor Hearth5arvl- ...1j, nit IY 1Ne11 Pemi9t ApplLcation Sr+pPfem <br /> er1L <br /> n' p (MIT SR# <br /> Jo RE ZJr !W rnn S i t Ya 55 lam, <br /> San. oa9 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions osP pterll force and effect.with Section 7000)of Division <br /> 3 of the Business and Professions Code and my /,06 <br /> EXplfation Date: <br /> License#: <br /> Contractor: <br /> Date: <br /> Signature: / <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of periury one of the following declarations: (CHECK ALL THAT APPLY) <br /> nsent to self-insure for workers compensation, as provided for by <br /> I have and will maintain a certificate of co <br /> erformance of the work for which this permit is issued. <br /> Section 3700 of the Labor Code,for the p <br /> uired by Section 3700 of the Labor Code, <br /> 1 have and will maintain workers' compensation insurance,as req ' compensation insurance <br /> for the performance of the work for which this permit is issued. MY workers <br /> carrier and policy numbers are: G 0 BZ <br /> Policy Number: <br /> Carrier: loSIt is issued I an person in <br /> i certify that in the per o 1the work for which this perril ns tion laws of California,a and agree at if I <br /> any manner so as to become subject to the workers' compe <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> ot— <br /> /Z l0 y Signature: <br /> Date: <br /> Printed Name: �r� <br /> rF is <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION OMP N ANION,INTEREST ATTORNEYS PEES,AND DAMAGES ASL,AND SHALL <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OFC <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> C-5'7 licensed authorized representative),hereby <br /> I, <br /> authorize behalf. I understand this authorization is valid for <br /> to sign this San Joaquin County Well Permit Application on my <br /> work Ian dated on the front page of this application' <br /> one(1) ear and is limited to the P <br />