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SEW RY:9103822918-5acra. , 0; 9-12- 0 ; 8:29AM ;RADIAN IN7 YNATIl 923 313 0302;# 2/ 2 <br /> tsrlre-leas f1:x. I rra�M <br /> Sam Joaquin c6le y elmAraatee. 'silhiicn;kffI W .__ _ .; A,O?Ic ioh'Sup,p ant <br /> JOB Agvnis - P# :SIRIF: <br /> LICENSED CONTRACTORS DECLARATION (L&W <br /> I Hereby alfsm that I em kensad under the provisions of Chapter 9(oommendng with Sarlion 7000)of Division <br /> 3 of the Suaineas and Professions Code and my license Is In full force end eH— <br /> Linens sr C42 gr-c r Expiration Date: //v//oz- <br /> Data: 00 Contractor ic-am4g <br /> Signature: %..___ --. TIM: 0�fkl&&%ejW <br /> Prinked rsamar <br /> WORKERS'COIAPENSATION DECLAKATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> SI have and will maintain a certiRcate of consent to seN-Insure far workers'compensation, as provided for by <br /> Section 3700 of the Labor Code,for the psfform ace of the work ferwhich this permit Is issued, <br /> KI have and wis maintain workers'ccmpensatlon insurance,as required by Section 3700 of the Labor Code. <br /> .�for the performance of the work for which ttfis permit Is Issued. My workers'compensation Insuranes <br /> Carrier and policy numbers aro: <br /> Csrrler. A94dr Policy Number. `LS0000 <br /> _I eeMty that in the performance of the work fvr which this penNt is issued, I shall not employ any person in <br /> any manner so as to become subiecl to the w vkera'compensation laws of California,and ague that If I <br /> should become subject to the workers'compensation provisions of SecWn 3700 of the Labor Code,I shall <br /> forthwith comply with these provisions. <br /> Date: Signature: <br /> Printed Name: <br /> WARNING,FAILURE TO SECURE WORKERS'COMPpNSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLMR TO CPJMNAL PENALTIES AND CIVIL 14NES UPTO ONE HUNDRED THOUSAND DOLLARS <br /> PPOR IN SM <br /> ION,( N to N 3a C( THE COMP VSAT N,INTERUT,ATTORNEY'S FEM AND DAMAGES As <br /> 1, Cktj-TWa- f rVR!q!H 1047 ik»nsed auUwraed r.Pneentadve� hereby <br /> autharhs�riy <br /> to sign this aan Joaquin County Well Permn Application on my behalf. I understand this authorization in valid for <br /> ane 1 I year and Is limited to the work plan dined an the frond page of this appliallon. _ <br /> z!z abed `57:8 00-z; des `Z 60 ClE 9Z6 `• 'QUI r6UTIS01 �3 6UTTTTJO 660J0 :/,g TUBS <br />