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i <br /> FROM West Hazmat FAX NO, 19166388613 Nov. 27 2000 12 : 09PM P1 <br /> 11 / 27/ 7000 12 : 50 20946711 / AGE STOCKTON PAGE 02 <br /> ' JOB ADDRESS.IF 4 M7 <br /> - 1P I"t 5A.WF%W <br /> IF <br /> v''.- n . l +� . _ lex, ii 'nn <br /> I - + �.. . ':t. k . ._ ?I �W 4;, ... . .r �.. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby rtfirm 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 effect. <br /> F <br />! License #: 5511 1 Expiration Date: 13 <br /> I ' Ciriiilk .0 <br /> Date: Q Contractor., <br /> rl/� ,(d1[n �' _�i� 1. <br /> SlgnaturY: <br /> Prints nd a O a _ <br /> IF <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declerdtions: (CHECK ALL THAT APPLY) <br /> _ I have and will maintain a certifcaly of consent to selbinsure for workers' oonFrisoticn, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> 1 have and will maintain workers' compensation Insurance, , as required by Section 3700 of the Labor Code, , w <br /> for the performance of the work for which this permit is issued. My Workers compensation insurance <br /> carrier and policy numbers are: <br /> Carrier _ ,_ Policy NurrWer: JJAM, Xr—„ <br /> I certify 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 subject 10 the workers' compensation laws of California, and agree that if I <br /> should become subject to the workerscompensation provisions of Section 3700 of the Labor Coda , I shall <br /> forthwith comply with those provisions. <br /> IF <br /> Data: 1/ Z 7y Signature ' ' <br /> Printed No <br /> WARNING: FAILURE TO SECURE WORKER((((((S' COMPENSATICGN COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (t100100J, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LAA13OR C' O�DE`. �— <br /> +• c.•�-+w�i'>^-� /`-I f/1'' /Urt•N/tc.rlt✓r7-r , ,. •_J(C: ..s7license holder), hereL• y <br /> tjajan6d <br /> hrerf _A V +41iten _ _ _ ■7{ ,ge(coxulting), tasipnthiston <br /> aquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1 ) year IF in limited to thin work pian dated on the Vont papa of this application. <br />