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\.. `1 <br /> .1 JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (commencing with 3ecbon 7000 of Divisiun <br /> 3 of the Business and Professions Code) and my license is in full force and effect. <br /> License#: 51 226$ Expiration Date, 04/30/2001 <br /> I <br /> Date: Contractoc _Sp_Ar_trum R:ptnrakinn . Inc <br /> Signature: "Title: Area MAnaner <br /> Printed name <br /> WORKERS' COMPENSATION DECLARATION j <br /> I hereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> _I have and wili maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which, this permit is issued i <br /> 1 have and will maintain workers' Compensation insurance, as required by Section 3700 of the Labor Code. <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> i <br /> Carrier: _ Sn.per i nr --­— Policy Number: WS 8 -A _ II <br /> _X_I certify that in the performance of the work for which this permit is issued, I shall not employ any person m <br /> any manner s0 as to become subject to the rker5' Compensation laws of California, and agree that if I <br /> should become subject to the workers' pen tion provisions of Section 3700 of the Labor Godo. l shall j <br /> I forthwith comply with those provisions. <br /> Date:_ I— I ^'ISL' Signature: !f <br /> Printed Name: lder <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION Ct4ERAGE IS UNLAWFUL.AND SHALL SUBJECT i <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.1, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES. AND DAMAGES As <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. i <br /> I, dim KlreiL+rr_Id ur of Spc+r-tr rm olio = <br /> a ion ,9n <br /> Ic by <br /> (C-57 license holder); here <br /> authorize ,117n Ly - it —of Wrii hl- C-n V i 1C r .,(consulting),to sign this San <br /> ( <br /> Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for one(1)year <br /> and is limited to the work plan dated on the front Page of this application. <br />