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FROM <br />07/141410ALL614 10;•:$ "1-.-M 1 916 S61 0430 SECOR-SACRAMENTO <br />: azi-na i i ' ' FAX NO. : 1916,638E613 <br />SECOR- SACRAMENTO 07/10/00 MON 18:58 FAX 1 916 861 0430 <br />i fr. T1-1 Ft fICR 0 4 /26/2000 O8!23 2694683432 <br />Z 002 <br />Jul. 11 2000 07:44RM P2 <br />Z 014 <br />PAGE 04 <br /> <br />::Stocdp4ipiln: Gott Ettvirohhientaqtealtnel'40.A;:littly:WIttcRilr!t:A j)icat I to :, <br />65q vt. 40S <br />2 <br />_ y ..41-7D-Dol <br />114y C ,oLt <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />hereby attirm Mel I air licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br />3 of the Business and Professions Code and my liryanse is In full friral 2nd effect. <br />Lloense r$:5 5 4 /I 77 Expl-riltion Date: / - o <br />' <br />Data: t"› Contiector: f:Aies 1-tflo.-..*A_. Ov:VV•••," (Pr p eSte•iikAre41,‘ <br />fret / MA-a-44trEr-' c 3°1 e. frt <br />Printed na7le: _ -C/2/tArr <br />WORKERS COMPENSATION DECLARATION <br />heieby affirm under penalty of perjury one e the following dociurations: (CHECK ALL THAT APPLY) <br />I have and wifl maintain a certificate of consent to 9elf-insure for worKeris` compensation, as pfOvided for by <br />Sedlen 3700 of the Labor Code. for the performance of the work for which this permit ts issued. <br />__Ziave and will maintain workers' compent;ation insurence. as required by Section 3700 of the Labor Code, <br />for the performance of the work for whiai Oils permit its ismued. My workeis' compensation insurance <br />carrier and policy numbers are: <br />__Xcertify that In the performencts of the work for which this permit isi5.5uad. I ahtlii not employ any person In <br />any Manner so as to become subject to the workerS' COMpeAnS2tian IDNArr, of Catiforma, and agree that if <br />shOuld become subject to the workers' c.empensatlan provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those pmvisiona. <br />Date: _ 0 q—/IT e'e) SignatUre: a-1P <br /> <br />Printed Narno: 411-7("C? 4-, <br />WARNING: FAILURE TO SECURE WORKS' COMPENSATION COVERAGE IS UNLAWFUL, ANU SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PeNALTIES AND CIVIL FINES UP TO ONE HuNDRED THOUSAND DOLLARS <br />(st ammo.). IN ADDiTiON To THE COST OF COMPENSATION. INTEREST, ATTORNEY'S FEES, AND DAMAGE'S AS <br />PROVIDED FOR IN SECTION 37136 Or THE LASOR CO <br />Policy Number: /9" c L1-6 6 0 <br /> (C-5/ licensed aueleriaed ropresontaVe). hereby <br />orixe Aref A U {.4 TL-71- <br />to sign Ws San Jaaquin County Well Permit Application On my behalf. I understand authormatiOnio valid for <br />1) ear dI d Is kinked To .the work lari date aort tho front poe of this appliciition.