Laserfiche WebLink
1126/2001 $FED 14:0 F." Cuuiiuul <br /> Comm [TIT9 ON %2t XLl L4:Ei t[�s iuslz/s7,1TT <br /> 1 Sen.Iaaqufn CaUrtly fnvirannsartal H$alth Sarvia-a,Unit IV Well Permit Appftadcn Srpplarment ' <br /> JOB ADDRESS: PERMIT SRM . <br /> LICENSED CONTRACTORS DECLARATION /(LCD) t <br /> I horeby affirm that I tim 11cenaed under the pmvisiotlB Of Chapter 9[cornmencine Sermon 7000)of Division <br /> 3 of tiu7 suslnes9 and professions Code and my license i5 In full force and effect. <br /> License ft: 41 Expirstion Data_ <br /> Date: $�Qr _ Corttrsctcr: r Gs/ 1 .r,'l/:��, 'r1 _ <br /> Signalute3: .!�d1c _ T!Ue• <br /> ! firlt�d notate: �� <br /> f <br /> i WORIKE.RS' WMPF-NSAM0N DECLARATIONS <br /> i f herabV afimn under penalty Of perjary one of the fallo%vinb declarations; ICHSCK ALL THAT APPLY) � <br /> _I have 2rtd will maintain a certlflmte 0 consent to sw hour±for workers'comPe,15ation,an provided fur by <br /> f Section 3700 of the Labor Code,for the performance of the work ttr which this permi~is issvatl. <br /> ]! ZI have and wL11 maintain wari%ers'cornpermatfan insurance,as required by Section 2700 of We Later Cvdoi <br /> 2 for ft performance of the work for which th a parmil is fssusc. fly workers'aornponsa*n insumnaa <br /> s rattle and pDricy numbers are: <br /> I I <br /> Carrier: 1 PalPcy Nurnkrer X13 - Ste ` -d j� <br /> I cestiry that in the perform-roe of the work for which thio perrrtlt is issusa', I shall not 8-Play any pe-son In <br /> —'any manner so as to become aub]act to the warkers'cramponsct)on ILyia of California,rind uree that if I <br /> should bwame subject to tha warkors'emmperisation provisions of Saatlan 3700 of the L.nbar Cade,t shall <br /> forthwith comply with these prnvisions. <br /> Date; Signature: <br /> Printed Name-, <br /> WARNING.FAILURE'TO SECURE WORMERV COMPEN3ATIG14 COVERAG819 VNLAWFUL,AND SHALL GUOJECT <br /> AN uw6QYSR TO CPJ)n"L PENALTIES AHG cnnL,FIN23 U1*TO 0INZ Iit.It 13*=TMUSANi0 VOLL.1= <br /> (5400,0M.),IN At]O=N to THE COST OF C0MPMg3A,Tl0r%INTEREST,ATi OMSIEY'S FZX3,ANC DAMAQES A$ <br /> PROVIDED FOR IN SECTION 3709 Of THR t-ABOR CODE. <br /> t, 15a _.i _ IJ r ct excr - (a)gn srtur•*fC-57 authorized represantative.J, <br /> I <br /> haraby euthaiixi(print mane)) ,.�-- <br /> to sign thia Sen Joaquin County Well Permit Application on my behaff. I undarstand Lhis authorkzatron is valid Tor <br /> arra(1)yearand is limilted to the work plats dated on the front pomp of aria epplleatlan. <br /> 5-77-2000!MI <br /> £d LJdi<S:Z0 TPUZ BE 'nON 2006 EES SOL, : 'U.N EN04d 4n„is2 psano.kC hi0u� <br />