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APR 13 '01 1w 52 WEST,GEb-ENG -t.EGC-530-662-0273 a <br /> 0 <br /> 3r <br /> ryt <br /> pti. 1 �a Wri 1ftxrtlT3sttblflerMlr�>r��l�� t' '�'MheNFPsrrnitApp <br /> � 814gpt�g43 " <br /> +�+1 rflj"`}b' � � ' <br /> e +• a-{ <br /> r � hJ✓1 f 1 ,�. "++ � F i "ifw . �-.t t h 'T r +.5+ S:• - ' - • +.� �� y-!� � .1tY'ft'/G ��'11,, <br /> RO <br /> T <br /> LICENSED CONTRACTORS DECLARATION (LCD1 <br /> J hereby affirm that I am ilcenssd under the provisions of Ghaptar 8 (commencing with seot+on 7000)Ot DIvislon <br /> 4 3 of the Business ane Professions Cocas and my license 1s In full force and effeot+ <br /> t <br /> Expiration Date <br /> ` <br /> Date',..�., .t ..,,� ) Contractor. c <br /> 1 <br /> ' Signature. Title: <br /> L� printed Ilan*-. JC Lirl &unc-vol _ <br /> 'L <br /> WORKERS' COMPENSATION DOCLARATION <br /> L <br /> I hereby affirm under penalty of perjury one of the following deolaretiona (CHECK AI.L THAT APPLY) <br /> I hsva and will maintain a acrilflcate of consent to seff-Insure for workefs'cornpan&ation, as provided for by <br /> r Section 3700 of the Labor Code, for the performence of the work for which thle permits issued. <br /> /I havQ and will ma:rdaln workers'compensation znaurenos, to required by Section 3700 of the Labor Code, <br /> For the parformanoo if the work for whioh this permit Is Issued. My workers' compensation Insurance <br /> carrier and policy oars are- <br /> Carrier,, .,, -- Policy Number:ZI --., <br /> certify that In tho performance of the work for which this permit is Issued, I shall not employ any porron In <br /> any manner so as to become subject to the workers'compensation laws of California, and agree tt 1t If I <br /> should b9come SAW to ahs wortcera'carnpenastlan provielons of Section 3700 of the L abor Cads, I shall <br /> forthwith comply with those provisions. 10 ____ <br /> Date', oq 13� C)l$l�r�ax rer <br /> Printoct Name: <br /> WARNING1. FAILURE To aECURE WORKER$'COMP✓rNSATION COVERAGE JS UNLAWFUL,ANA SHALL SUI.IECT <br /> AN♦EMPLOYER TO CRJMINAL PENALT1118 AND CIVIL FINES UP TO ONE HUNDR90 THOUSAND DOLLARS <br /> (t{40CrS10a,),IN ApDITION TO TM5 COT OF COMPIEN8A110N, INTGRS$T,ATTOIRNSYrS FeEA,AND DAMA(;Es As <br /> PROVIDED FOR IN SECTION 3748 OF THE LOOR COD <br /> IP <br /> �f y Ilconsed authorized 1`e011e0I.Whra),111401by <br /> •—per— — ,+.�� ...,.,._,.�.�-.—•.. �' .�.�.�..�...r <br /> . to sign this San Joaquin County Well PorrtmltApplicatlon on my behalf, t undarotand thla authorlsaDon is velld for <br /> one(1)your and Is#Imlted to the work plan dated on the front page&this application. <br /> 8.17 0001 MI <br /> _._ _�� �w.�r �nw+,. .rte ♦..• <br />