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JOB ADDRESS: Z ` zct� PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I acct licensed under the provisions of Chapter P(commencing with Section 7000 of Division <br /> 3 of the ausinoss and Professions Code)and my license is In full force and effect. <br /> Expiration Date: D' 0 <br /> License 9. <br /> Date. Z.�- contract r_ ; <br /> Signature: Title:_ <br /> T(`Pj S Cr1 <br /> Printed name: rlG�/I�rl°� !'_r•_ �_ fs QJ ZZ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fpibwing declarations: (CHECK ALL'THAT APPLY) <br /> I have and will maintain a Certificate of consent to serf-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, I <br /> for lite performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier anpoiic numbers are: <br /> Carrler�;[r CArn .�� _Policy Number: /-r --- <br /> which this permit Is issued,l shall not employ any person in <br /> I certify that in the performance of the work for h <br /> any manner so a5 to become subject to the wcfkefS'compensation laws of California,aro egree that if i ; <br /> should become svbjeot to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. i <br /> Date. Signature:_,. - _---------- ~� <br /> Printed Name: ----�—�- <br /> WARNING: FAILURt TO SECURE WORKERS'COMPENSATION COVERAGE IS uNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CWMINAL PENALTIES AND CIVIL_TINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> I$J0 pip IN FOR ADDITION IN OTO TI IE ION 370 COST <br /> X I.A pR OFCOMCODPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> 1 Cil I"6I C•s7 Iicertsa holder), hereby ; <br /> authorlxc_ a ! L rb' Ur rLiCon� �ulting) to sign thl5 San i <br /> JozgUln County Well Permit Application on my behalf, t understand thla authorization is valid for one (1)year j <br /> and is Ilmitsd to the work plan dated on the front page of this application. <br /> ti.' <br />