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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 #: -WOO Expiration Date: 7/0/ <br />Date: 5/5/0 / Contractor: /./00a/C /1, 6 iy <br />Signature: 25:4-el--6( Title: • • <br />Printed name: Wee xi/ P 6- /./e.A_Cf,G7 /Zw. <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 />><...1 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 workers' compensation insurance <br />carrier and policy numbers are: <br />Carrier: r—ce 4-1 Policy Number: 6 g -* 0 0 <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 b6come 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: 6/C/0 Signature: / <br />Printed Name: Le157.1 e Ge>00e/e-vG-e.9/ <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 />(C-57 licensed authorized representative), hereby <br />authorize <br /> <br />27a vfe-/ //•;// <br /> <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />5-17-2000 / MI <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />3"44i <br />0 E S S : /2// --5: PERMIT SR#: 9--Ce r6 9 <br />VO 2.9vd <br /> <br />'F.41=f17-1 F-EVE89VE0 69:01 000Z/61/0T