Laserfiche WebLink
JAN-14-00 FRS 09 :34 7078648886 P. 02 <br /> San Joaquin Courtly tcnvironmental Health Services,Unit lV 1111fe1t Permit Application Supplement <br /> JL)E ADDRESS: 2/0 3 � PERMIT SR#:. <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> iereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Divisor <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License# C y"7 = S a 1 a 5 Expiration Date: 2��-?1-9 00 <br /> hh i <br /> Date. _— 1�1 0 _ Contractor: P� �2r.1 L%10y�iortf .rttc' .^_____�_ <br /> X& Signature <br /> i <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I -,ereby affirm under penalty of perjury one of the following declarations (CHECK ALL THAT APPLY) <br /> I have and will rnarntarn 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 /> x I have and wilt maintain workers' compensation insurance as required by Section 3700 of the Labor Cade <br /> for the performance of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are <br /> Carrier: -.. +fit /? r Policy Number <br /> --I certify that in the performance of the work for which this permit is issued. I Shall riot employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that If 1 <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code. 1 shall <br /> forthwith comply with those provisions. <br /> -3' Date: ------------ <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> P FOR N SECTION 371)6 OF THE LABOR <br /> ($100,000.),IN ADDITION TO THE COST OF <br /> CNOSAATION, INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> Scorr FT'fZl4-tE (C-57 licensed authorized representative), hereby <br /> to sign this San Joaquin County Well Permit Application on my 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 thio application. <br />