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DEC 1 '[40 12:3S r-lEST-GE:7ENG.--i�I±GE-S3t3-S62�273 P.2i2 <br /> San Jozquin County al 5 Made, Unit IV W01 Parml ca on t <br /> 066 5 <br /> JOB ADDRESS: PERMIT SR#t <br /> d - u� O oLY e6, <br /> /9/0 coG/!7�J C14,6 34-1 <br /> LICENSED] CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licer►sad W-1der the provisions of Chapter 8 (cornm®nctng vAtii Section 7000)of Division <br /> 3 of the Business and Pro'essians Code and my!'cense Is in fuii 'orce and effect. <br /> �1G8PSC Exp;rotlon Date: <br /> Contractor �/t l� �•'� ;� =c-- I <br /> Title; E� <br /> signature. [ <br /> Pr1n`eo name. 121._ f <br /> WORKERS` COMPENSATION DECLARATION <br /> I h$,-eoy affirm under penalty of per,'urv, ens of t'''ne fallowirg declarations; (CHECK ALL THAT.APPLY) <br /> �', `,, �. I have gnd will md:rtaln a certiflc2!e of consent to se:f•1n5ure for work ars' compensation, as prav,ded fcr by <br /> y <br /> Section 3700 of the Labor Code, or me performance of t.ne N%,ntk for w•hlch th'F permit is issued. <br /> -,-')'have anc wlil mmimlaln workers' Compass tlon Insurance, as regt;ired by Section 3700 of the Labor Code,;' <br /> fcr tho perforrnarlce of the work for Which this perrnit Is )ssued. My workers` compen5e4lon insurance <br /> terrier and policy Pumbars are; <br /> Carrier: policy Nu mbar: _7[.3- ;.L- 94 <br /> i asr1y that in the performance of the work for which thla permit is issued, I aha11 not employ any person in <br /> any manner so as to become subject to the wo-kers'compenseliCr.iera•9 of Calirarnls, end spree ihat If I <br /> sF ould becprne sufoleat to the workers'compensation provisions of Se.ticn 3700 of the Labor Cade, I shall <br /> forthwith Ornply With thosel provisions. <br /> Date <br /> Printer! Name: <br /> WARNING: FAk'URE TO SECURE WORKERS'COMPENSATION COVET AIS 15 UNLAWFUL,AND SHALL allBJECT <br /> • AN EM!'I.OYER To CRIMINAL PENALTIES AND CIVIL PINE$ UP 70 ONE HUNDRED THOUSAND DOLLARS <br /> (S10a,64t).), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVICED FOR 1N SEOT104 3706 OF TFST� LABOR CODE. <br /> / (0.37 Ilormood autharizad rapresvMtativP), hereby <br /> authorize— t f 1,r/C 6L< <br /> to sign this San Joaquin County Well Permit Application on mybehalf, 1 understand IhIs author4ation Is valid far I <br /> one(1)ytar and Is Iirnited to the work plan dated an tho front page of this apPllvatlotr, <br /> .3•t7!•2Q�! — <br /> 12/19/2000 TUE 12:37 (TZ/R3 NO 671.dl 01002 <br />