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i <br /> ,r s • <br /> JOB ADDRESS: �Iqa' 94V Ve- PERMIT SR#: <br /> LICENSED 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 Professions Code) and my license is in full force and effect. <br /> � <br /> License#: -! r (2 S7 Expiration Date: <br /> q C <br /> Date: fl'~ [ `. Contractor: L�� <br /> Signature: Title: <br /> Printed name: _ 4v, h i �� r^-i J ___...., <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 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 /> CarrierS: 4701t " Policy Number: j�.77 �yr <br /> _ I cer#ify 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 laws of California, and agree that if <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> 'Date: Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKI=RS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND 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 /> l (C-57 license holder), hereby <br /> authorize of (consulting),to sign this San <br /> Joaquin County Well Permit Application on my behalf. I 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 />