Laserfiche WebLink
Y ! � <br /> San Joaquin County Envkonmontal Health SarvMaltr Unit IV Will Permit Applicaationn Supplement <br /> JOB ADDRESS: 2��/"trrAY (a,6 0,L&-- PERMIT SR#: <br /> .51nCeT60, CA <br /> LICENSED CONTRACTORS DECLARATION (k) <br /> I hereby affirm that I am ficensed undar the provisions of Chaptar 9(commencing with section 7DOO)of Division <br /> 3 of tris Business and Professions Code and my license Is U full force and affect. <br /> License H: L5= 7 Expiration Data: <br /> Date' �L'I Contractor: <br /> Signature: Tltie: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under pensay of perjury une of the following rieclarations: (CHECK ALL THAT APPLY) <br /> ,._I he"and will maintain a certificate of consent to self-inure far workors'compenaiUon, ac provldoc for b/ <br /> Section 3700 of the tabor Code,for the performance of the work for which thia permit is issued. <br /> I have and will maintain workers'compensation Insurance, as required by Section 37DO of the Labor Code, <br /> for ft performance of tha work for which this permit is issued. My workers'compensation insuranoe <br /> carrier and policy <br /> ,numb* <br /> rs re. <br /> Carrler:�5 , 1 �o policy Number: <br /> I certly that in the performance of the work for which this permit Is issued, 1 shall not employ any person in <br /> any manner to as to become subject to the workers'oompansation laws of California,and agree that it I <br /> should become subject to the workers'oompsnsatfon provi a of 3 on 9700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> -pets! <br /> _ � / StpneDln: <br /> !'r(nted Name: <br /> WARNING:FAILURR TO SECURE WORKERS'COMPENSATION COVERAGE 0 UNLAWFUL,AND SHALL SUBJECT <br /> AN OMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNEB UP TO ONE HUNDRGD THOUSAND DOLLARS <br /> (3100,000.),IN ADOMObJO THE COST OF COMPENSATION,WaREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> P11pV1pQp POR t 7 OF it OI THE LABOR COPk. <br /> 4 dpMturo ofGi7 tfeenaed suthoMtmd reprrenutive). <br /> frsrebys (grin ) sk4,P.PJF /strJfn <br /> to sign this Han Josquln County Well Permit Application on my behalf. I understand thla k"horttallon k valid for <br /> one(1)year and Is larked to the work plan dated on the troll page of this epplioatlon. <br /> 5-1741000/110 <br /> 1 <br /> E0/E0 39Vd aba3S 0£1'0L5Ci9T6 00:60 o00zrt3L/F0 <br /> E0 39Cd DNI 9NI-1-1IdG 3GVOSVO IT998699161 Eb:OT 600Z/9Z/E0 <br />