Laserfiche WebLink
10/15/2004 10: 41 9166385 CASCADEDRILLING • 1346E 02/02 <br /> 10/15/2004 10:30' 2694671 raat4iuuKiuiv r .11 <br /> San Joaquin Co Environmental Health Department Unit IV Well Fermit/tppllcation Supplemer t <br /> JOB ADDRESS: 6424 W, l.3ANN'll A-ve. PERMIT $R;I!:_'52i LbL <br /> r o0i~ , Gf{ 99245- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing w th Santlon 7000)of Divi;ion <br /> 3 of the Business and Professions Cade and my license Is In full force and effect <br /> License 0, Expiration Dale:_�=?)I ' <br /> oate: 'o l c Actor LLr�o r r l l t n.0 n L� <br /> Signature: <br /> Printed name: <br /> WORICIERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations; (CHECK;(SNE) <br /> I have and will malntaln a certificate of consent to self-Insure for workers'compensation,as provided f Ir <br /> by Section 37ou of the Labor Code,for the performance of the work for which this aermit is issued. <br /> L I have and will maintain workers'compensation insurance, as required by Secti m 3700 of the Labor Cc de, <br /> for the performance of the work for which this permit is issued. My workers`cornpnnsetion Irtstimrlce <br /> carrier and policy numbers are: <br /> (sr Carrier JCL\LMkD, (V A/�Z_Policy Number, Oq e J'J_ CZ 15L! _ <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 Calirornia,and agree that If <br /> should became subject to the workers'compensation provisions of Section 370)W the Labor Code, I sl call <br /> r`+ forthwith comply with those provisions. <br /> Expiration Date; -I 'CS Signature: r w <br /> (l\ Printed Name: <br /> WARNINC:FAILURE,TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL.AND SHALL SUBJ;CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINKS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'; FEES,AND DAMAGES I S <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A THORIZA ON FORDTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (sighotum 00-67 11censed authorized reprosenGtl m), <br /> hereby authorize(print name)__ <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this m4horization Is valid for <br /> one(1))(oar and is limped to the work plan dated on the front page of this application. <br /> B-29.02 r MI <br /> EM 29,0U01 <br /> 6MI04 <br />