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05/15/2000 08:21 209468 FIFTH FLOOR • PAGE 03 <br /> Fair.toa9uirY Coult4y Epviranmental H�altk,S®rvrces,,Unit lY aNe'lleml t APpll°�1On SPlemerit <br /> JOB. MDR SS <br /> IT sR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I 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 <br /> �efffec�t., nom/ <br /> Expiration Date: <br /> License#: t i <br /> Date: ���_ _.,a–I�—`r Contractor. Q r <br /> - aA Title:_ <br /> Signature: <br /> r <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have and will maintain a certificate of consen�an�of the work forfor kwhich this parisationermit s,as provided for by <br /> Section 3700 of the Labor Code,for the Performance <br /> have and will maintain workers' compensation insurance, <br /> an e, required <br /> workeSection t Labor ode, <br /> rs' compensationinsurance <br /> he✓I <br /> for the performance of the work for which this permit <br /> carrier and policy nurs are: <br /> nb Policy Numbed <br /> Carrier:34Ay erson in <br /> t <br /> I certify that in the performance of the work for which this permit is issued, I shall noemplo any p <br /> any manner so as to become subject to the workers' compensation laws of California, and agree that if I <br /> to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> should become subject <br /> forthwith comply with those provisions. <br /> l l 41 d rj Signature: <br /> Date: Printed Name:r KytP A <br /> L,AND$HALL <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERA ATTORNE S E IS FEES,D O DOLLARS <br /> ES AS <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED FOR 114 SECTION To THE COST ON 370 OFT THE CODECOMPENSAT. INTEREST, <br /> '-• (C_57 licensed authorized representative),hereby <br /> , <br /> author"'-n _ <br /> Well Permit Application on my behalf. I understand this authorization is valid or <br /> to sign this San Joaquin County lication. <br /> one(1) ear and is limited to the work plan dated on the front pa a of this ap <br />