Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 701 East Charter way, Stockton 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 force and effect. <br /> License#: 680227 Expiration Date: 11-30-2008 <br /> Date: <br /> 1-24-08 r,)ntractor: Advanced GeoEnvironmental, Inc. <br /> 'f <br /> Signature: _i� Title: Vice President <br /> Printed name: Robert Marty <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> have and will maintain a certificate of consent to self-insure for workers' cop Sensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> X 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. 0 y workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: state Compensation Insurance Fund policy Number: 1317474 <br /> 1 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 /> 01 October 2008 <br /> Expiration Date: Signature: <br /> Printed Name: Robert Marty <br /> WARNING: FAILURE TO SECURE: ORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> F$l`&"M1A4 IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S )EES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION PIM OF THE LABOR CODE„ <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I° Esignature ofC-RT licensed authorized representative), <br /> hereby authorize Sprint name) <br /> to sign this San Joaquin County Well Permit Application on my behalf, I understand this authorization is valid for <br /> one EM year and is limited to the work plan dated on the front page of this application„ <br /> LLC9_MD/MI <br /> EHD 29-02-001 <br /> Fmm4 <br />