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N COVNtY CfVATHOu tSE JOB ADDRESS : 111 E , WF01K AV � , , SCMt KION PERMIT# : f r LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division 3 of the Business and Professions Code, and my license Is in full force and effect. License # 6lot 6 lot Expiration Date 6 J 30 103 Date 5Ix9 I Vol, o tractor MITCMttI. DRILLINf rEoNVIKVNH0%l1oAlL `.i ii Signature WORKERS ' C MPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following decalarations: ❑ 1 have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. iI have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Carrier STATIE COtAFEKSATON € OND Policy Number 15 $ b6y `} 00 ❑ 1 certify that In the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California , and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Date Applicant WARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ( 100,000), IN ADDITION TO THE COST OF COMPENSATION; DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES.