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JOB ADDRESS: 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 /> License#: r 90 (7)D--? Expiration Date: <br /> Date: -On Contractor: A(--E <br /> Signature: flMx(�A� I Title: (eo6f5 <br /> Printed name: � lug / l I ��Ma✓I <br /> WORKERS' COMPENSATION 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 /> Khave 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:( c <br /> Carrier: ,)74 F.. VJ Policy Number: I3 I7y7-/3g <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 /> 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: P [U(, Signature: <br /> I <br /> Printed Name: ( iG vn /"'�^I l/hG✓I <br /> WARNING: FAILURE TO SECURE WORKERS' 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 /> I, (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 />