Laserfiche WebLink
I <br /> I <br /> San Joaquin County Environmental health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: I bo"-( T 5h,�Zc-�/ --L PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATIONL( CD} <br /> I <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# !�J b J I to 6 _Expiration Date_ j�( 1 ob 1 r) <br /> Date: Co 0 or. ( , <br /> I � <br /> Signature: Title: C)am '-f)6-0 LLJ2a%-1—, <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 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 and policy numbers are: <br /> Carrier. ��R ti'1 Policy Number._ _ <br /> 1 b 7�Cfl j <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 /> Expiration Date: I I 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 FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1o0,000.),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 /> AU ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC-57 licensed authorized representative), <br /> hereby'authori print name <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1I year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 Mi <br /> EHD 29-02-001 <br /> u��ma <br />