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10. <br /> JOB.ADDRESS .77 <br /> PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I I ereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 of Division <br /> �r 3 of the Business and Professions Code) and my license is in full force and effect. <br /> -� License#: <br /> A Expiration Date: <br /> Date: �7_�.� - 0 Contractor: <br /> Signature: ' Title: <br /> f <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION = <br /> k; 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 chis permit is issued. <br /> k1 have and will maN.intain workers' comperisation insurance, as required by Section 3700 of the Labor Code, <br /> i k <br /> for the.performance of the work for which this permit is issued. My workers' compensation insurance. <br /> carrier and policy.numbers are: <br /> Carrier: �Uvj Policy Number:'_ 1317 7 1 934- <br /> certify that in the performance of the work for which this permit is issued, 1 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: Lb Ld_ Signature: <br /> • I j r <br /> Printed Name: ic, IM Cv-� <br /> tf - <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL4 AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100;000.), 1N ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (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(i)year <br /> T and is limited to the work plan dated on the front page of this application. <br /> - F <br />