Laserfiche WebLink
SE1�T 8 SPErcTRt1M; 5 t8 1 is Igi <br /> 1 <br /> 1 San .loo Irur�CEnvrranme'ntrtl Health i <br /> SerYces, Unit IV Weil Perrnit A lica, , <br /> y - oir'tY n <br /> W5uppl6rt1en# - <br /> 1 JOB ADDRESS. _..��..-. , ,7t__,_ �� . iV PERMIT SR.#• �,.----...___.. - - �. <br /> LICENSED CONTRACTORS DECLARATION ( ,C � <br /> I Ifr'reby affirm ifrat I am licensed under the provisions of Chapter 9(coNmri encAng with 5ectidn 7000) of Divisor I <br /> 3 r-f the E}c.rslness and C We, and my license is in full force and effect- <br /> �1 22i�r 04130/200 3 <br /> E.ir rnsc�#: r- >'7# _i xi�ir ition t7a1e: _----._............. - <br /> Date': �.. f L _�! � � t:.cYrttrr.ir::lr�r: �_�t,'`�twaCiFm t✓x_��3.©r z t.14�rr i..__a n t <br /> 5fgnature: �...._ 'Tittle: Oper.3t: ,tails Ff, rtr�c�.r' <br /> Printed name: BI-ericia. �.r�twt`.or el <br /> _.......................... ......,...,.__—. ................. <br /> WORK RS" COMPENSATION DECLARATION <br /> I hereby aftirrrt under larrnally c)f.l:e:rjury ortc�of the fcsllCrwinc declarations: (CHECK ALL THAT APPLY) <br /> i <br /> I parva~and will maintain a coo-lifrc.alt,(,#rrrrayer�t !o sell incureltrr_worfcers'_c�rrmpens�aticrrr;as}�rt�ict�f fear-try 1- <br /> - �! ec[iorr 3700 of tliE+t.;�k>�3r Cur3c,rtri bhp fr iinrmar rc a <br /> ('d the word for which this permit is ii�mued. I <br /> XI have and will inaintain w wkers' cumj*n5ation inswance, as required by Section 3700 of the Labcf E;,0e, j <br /> for the perfornn anue of the wart.for which This pwirnll is issued. My workers'compensation itistirance j <br /> i unrrfor Ind pr)lic:y n.m7b€:rrs aro, I <br /> Carrier: Arne_x' r.,.crate Malo.—i5'l. Policy Number: 33303575800 i <br /> .._,....._..._--...._-.__.__._:.......-------_--...........:,.._._.. <br /> -- i <br /> _—_i certify that in 9*performance of',th-e mik for vvtlich this permit is issued, I sliall not ernl,Ai►y any persoo in <br /> any manner so as to become subject to the workers Compensation laws of California, and agree that if I !. <br /> ahouid b@G mie subject to Me workers'r oaipensation prov -tins of Section 3700 of the Lakx r Ccxin, I shaft <br /> forlhwith coi with those Iirr.wisions. <br /> �.� <br /> Date: ...... Sigmalure. _..._ —_..__ —---._........_.................... <br /> .,. <br /> l'rintec#hlarrne: 1:-.r:i,r1 <br /> i <br /> WARNING; FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES tip TO ONE HUNDRED THOUSAND DOLLARS i <br /> (Sioo,000.), IN ADDITION TO THE COSTI,OF COMPENSATION,INTEREST,ATTORNr=Y`S FiMES,AND DAMAG[S AS <br /> PROVIOED FOR IN SECTION 3700 OF THE LABOR CODE; <br /> r <br /> f3> e rrtli� C`.r'�awtc�r,cl �.yl' r <br /> I, �f7F a I r tlrrt r'fx�rl c7r" - sr nature-ofC-57-f1c+3nsed-rrutharf�d-rQ ;=`--- ` '_"�'-- <br /> tterelry authorizer(print name) ,..,, LX0—r1.... .. <br /> to Sign INN Sen JCM4011 Caai,nAy Well permit Application on my behalf, I understand thle authorization Is valid for ! <br /> one(1)year and is limited to the work plan(fated on the front page of this application. <br /> 17-2000;Mi <br /> i <br />