Laserfiche WebLink
San Joaquin County Environmental Health Service$, Unit IV Well Permit Application Supplement <br /> tl <br /> PRMI OZ. <br /> T SR#: D <br /> 00� <br /> JOB ADDRESS : <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 Cade and my license IS In full force and effect. <br /> License M <br /> •f F apiration Date: till t <br /> k/ ii TrJCr <br /> Date: _ /Zto / o cantractl <br /> fL <br /> Title: <br /> Signature: <br /> Printed name: Z� YlS� h P✓uwe✓ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL., THAT APPLY) <br /> ors' compensation, as provided for by <br /> I have and will maintain a cel Of consent to self-insure for work p <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' compensa0on Insurance <br /> carrier and policy numbers are: <br /> carrier: fn4t IG 5 Pcarke� <br /> Polley Number. m UJ c:i �oCpS>� <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 /> nsation provisions of section 3700 of the Labor Code , I shall <br /> mould become subject W the workers' compe <br /> forthwith comply with those provisional <br /> Date: 7 2a o_� Signature: <br /> till <br /> Printed Name: C) rYlMPENSAI <br /> WARNING:OYER To CRIMINAL PENALTIES AND CIVIL F Ne RKERS' 00L UP TO ONE HUNDRED THOUSAND DOLLpRSON COVERAGE 19 UNLAWFUL7 AND SHALL U�ECT <br /> AN EM <br /> PROVAS <br /> IDED FOR SECTION 97 8 O THE OFLAI3O LABOR <br /> INTEREST, ATTORNEY73 FEES, AND DAMAGES <br /> r+ /!ro (C57 licensed authorized representative), hJfor <br /> 4 <br /> All ... +++ lr authoriza AP <br /> lieatlon on my behalf. I under stand thisauthorization Is va <br /> to sign this San Joaquin County Well PermitP <br /> one (1) year and Is limited 10 the work plan. dated on the Trend Page of this application. <br /> 91.17-20001 MI <br />