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FROM West Hdzmat FAX NO. 19166388613 May. 10 2000 03:09PM P2 <br /> 05/10/2000 09:37 2094671118 AGE STOCKTON PAGE 02 <br /> 'JOB ADDRESS:_ PEF4 <br /> LICLNSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> 3 of the Business and Profnssions Code) and my license is in full force and effect. <br /> License#: 55 LZ 9 Expiration Date: D/- <br /> Date- -/ Contractor: WF,,'�T P/a - <br /> Signature C ry. ` <br /> Title: Nem,/z• <br /> Printed narpa�� G�f-Pm,o �,4 - <br /> WORKERS' COM PP-NSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will 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. <br /> I 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 /> Carrier: �V kLG/zS _ Policy Number. u/ i 5 <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 to the workers' compensation law$ of California, and agree that if i <br /> should become subject to the workers' compensation provisions Of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions, /J <br /> Date: S /U �> Signature: Ll r/�U1xe�— <br /> Printed Name: ,'2., �H`r+-�► % ,/-�d� .Y�z�r� <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 19 UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANL)CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (G-67 licensee holder),heroby <br /> authorize of n aV nJC j.0 GF 4 �,}} <br /> ny;44f\tQ^ 1 (consulting),to sign this San <br /> Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (t)year <br /> and is limited to the work plan dated on the front page of this application. <br />