Laserfiche WebLink
JON-1-2004 15:25 FRON:ENPROB 5305892230 :0: 12099480621 P.2 <br /> UU/U1/LUU4 10:U5 MA 'Gila U45UIS qy Vuz <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit ApplleatIon Supplement <br /> JOB ADDRESS:, '�7a .f/�r�A01. 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 farce and effe <br /> License T77 0 6 Expiration Date: <br /> Date: Contractor: <br /> Signature: Title: <br /> Printed name: <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 wilt 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 Cade. . <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier arid <br /> /policy nnumbers are; f <br /> Carrier- <'r^ L � T S �UNrs ' policy Number: '77'36';—��✓7 <br /> I 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 p isiens of Section 3700 of the Labor Code, I shall <br /> forthwith com ly 'th those provisions. <br /> r <br /> Date: Signature: / <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL SUES up To ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED iROV/IN ADDITION TO THE C05T OF <br /> IN SECTION a7 fi OF THE LABOR CODE ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> I <br /> i f z r (C57 licensed authorized representative).hereby <br /> authorize Yom' &C 5der <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(1)year and is limited to thg work plan dated an the front p39e of this application. <br /> 547.20001 MI <br /> 06/01/2004 TUE 16:27 [TX/RX NO 56641 Z002 <br />