Laserfiche WebLink
ILI <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: /6 �• PERMIT SR#: 04 C3 �� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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#: c-57 7 17 57/C) Expiratio i Date: / <br /> Date: �C - 1 0 (4 Contractor. C.t CGL e �f`'I ! ! fl <br /> Signature: <br /> Title: 7 ort a C( e <br /> Printed name: Ve, Q <br /> ex <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following eclarations: (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 /> I 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 <br /> ,,numbers <br /> �are: f r1 <br /> Carrier: dS t�GZ / v �n S T PolicyNumber: 5-3 / — <br /> I certify that in the performance of the work for which th s 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 p ovisio f Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Dater Signature: <br /> Printed Name: CIA 0e a Y'\ <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES P TO ONE HUNDRI=D 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 /> 1, 4Ch ap rV 1 a n (C-57 licensed authorized representative), hereby <br /> authorize Oa.1� <br /> to sign this San Joaquin County Well Permit A ication on rny 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 />