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e v*ivaoxr .a I <br /> fI <br /> /DOZ ZZ4 <br /> r— ,lo�ayufn County Environm"w He lth Services,Unit IV Well Permit Apptic a 355 nt <br /> o <br /> JOB ADDRESS:37 PERMIT SR#: <br /> < P 4902,Z} � <br /> LICENSED CO RACTORS DECLARATION (LCD) <br /> 1 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 /> 1776rF I Expiration Date: 6 7 <br /> License 7t:I it 1/ P CO Dateg/� �d Contractor 2,,,4-r [/Title: _.-- <br /> Signature: — <br /> Printed name: <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 /> x 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 workPri compensation insurance <br /> carrier and ptolicy/ numrberS are <br /> t <br /> _ <br /> Carver. _S7�i'f I `N o+ Policy Number: WC <br /> - _ � <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 laws of California,and agree that if I <br /> i should become subject to the workers'compensation provisions of Section^700 of the Labor Code.I shall <br /> forthwith Comply with those provisions. > ` <br /> 1 <br /> Date. / U / - Signature: L <br /> Printed Name: ... <br /> iog7Dfc' '1 <br /> WARNING:FAURE TO$EcuRE <br /> I$UNLAWFUL,AND SHALL <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARSUBJECT <br /> (3100,000.),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 /> (signature efC-s7 lioonsod authorized mprrxermtive), <br /> D // L R it u,T� •.11, <br /> hereby authorize forint names l Y pSq /(0.eiCh f- __.�—��-� <br /> to sign this San Joaquin County Woll Permit Application on my behalf, 1 underStand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this aPPllCstlon- <br /> 5-17-2000 1 MI <br /> v IUIFL FRLIE.E12 >r* <br />