Laserfiche WebLink
CONDOR Fax:2095320773 Apr 18 "'2 14:12 P.02 <br /> A-20-202 1 :59PM FROfw...i__aRK WELL.•• INC. ,209a625S97 „0110 P_ 1 <br /> C,IJNDLk kax:Mb620773 Apr 18 '02 13:42 P.x <br /> Sect Joaquin Coen Environmental Health Deepartment Unit IV Well Perfnit Applicatian Supp matt <br /> JOB ADDRESS: �� 14 <br /> PERMIT say: OD1 3 1 1 <br /> LICENSED CONTRACTORS DECLARATION (LgJD <br /> J 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 /> L9cense# 'J r d p <br /> a Expiration Date: <br /> Date=_ 49 �1 h Contractor. G e, <br /> Si�riature: Title:. SSC <br /> Primed name: _ �. <br /> WORKERS'COMPENSATION DECLARATION <br /> J hereby affirm under penatty of perjury one of the following declarations; (CHECK ALL THAT APPLY) <br /> _I have and Mil 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 /> '�t have and wdA maintain worketV compensation insurance,as required by Section 3740 of the Gabor Code, <br /> for the pertormanco of the Mork for which Chis pemit is issued. My workers'compensation insurance <br /> Cattier and policy numbers are: <br /> Carrier: UKfft ? ?4 <br /> 1ity Number, 0 q_9 " 114 <br /> —i Certify that in thf�performance of the work for which ihis permit is issued. I shall not employ any person in <br /> any manner so as to become subject to the workers'cumpensatlon lar+rs of California,and agree that V <br /> should become subject to the Nitworkers'com en atlon provdslons of Section 3700 of the labor Code.I shall <br /> forthwith Com with those provisions. 0 <br /> Date' 'i! D�- sigftbtum. <br /> Printed Name: — <br /> WARNING:FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND <br /> SHALL SUBJECT <br /> AN EMPLOYER TO CMLINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S100,OM),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PR FDR IN N V706 OF TH LASOR CODE. <br /> 1, (signatuft viC 57 1icenasd authofized repreSentlyfts), <br /> hire 'y atrtherise(prW Harps) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undertrnd this authorlizatkm is varld for <br /> arm(1)VON and ie limited to the work plan dated on the front page of this application. <br />