Laserfiche WebLink
07(03!2007 08:59 2094beA* EHD 40 PAGE 02 <br /> San Joaquin County Environmental Health Da rtment Unit IV Well Permit Application Sup <br /> piemenf <br /> JOB ADDRESS: IJ� t � yv PERMIT SR*:. <br /> LICENSED CONTRACTI �t5 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,.Busiress and.Professions Cade and my lire a is in full force and effect. <br /> l!cense# �p S iration Date: 1 �) <br /> Date: 0 Contractor: Pr' S> 0 PP <br /> Signature: Ithispe <br /> Title: —7 5yv)CVcn sle-✓' <br /> Printed name. 1ytft7RKMPE ATIDNDECLARATION <br /> I•herebyaffinn under penalty of perjurthefoll I Ing declarations: (CHECK ONE) <br /> I haveand will maintain.a certificsent to elf-insure for workers'compensation,as providedfor <br /> by:Section 3700 of the Labor Coe parfor ante of the work for which this permit is issued. <br /> have and will maintain workers' ation in urance,as required by Section 8700 of the Labor Code, <br /> for the performance of the work fthis pe it is issued. My workers'compensation insurance <br /> carer and policy numbers are:Carrier: 11io/L & _ _ ollcyNumber:I certify that in the performance ok for wh h this permit is issued, I shall not employ any person In <br /> any manner so as to become.subject to the worke 'oempensation laws of California and agres that if I <br /> should become subject to the workers'compensa n provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiratlon.cate: /40—?) Signature: <br /> Printed Name* C- <br /> WARNINGt:FAILURE TO SECURE WORKERS'COMPENS kTION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL Fit 96 UP TO ONE HUNDRED THOUSAND DOLLARS <br /> IN ADDITION TO THE COST OF COMPENSAI ON,INTEREST,ATTORNEY'S FEES,AND DAMAGES As <br /> PROVIDED FOR IN SECTION$700 OF THE LABOR CODE <br /> THOR17_ATION FOR OTHEf2 THAI C-57 SIGNING PERMIT APPLICATION <br /> 1 I (signature ofC-57 ucensed authorized representative), <br /> hereby authorize(print name) 01\'i 11Avk <br /> to sign this San Joaquin County Well Permit Application n my behalf. I understand this authorization is valid for <br /> one ll)year and is limited to the work plan dated on the nt page of this apphoation. <br /> 8-29-021M1 <br /> EHD 29.02-00 l <br /> WMA4 <br /> Z0/Z0 39bd 9NIldWCS NOISI032ld bL9tLEZ0T5 ZO:ZT L00Z/E0/L0 <br />