Laserfiche WebLink
SEP 05 2002 3: 22PM HP LASERJET 3200 P•2 <br /> OorOor.Onz 14:29 289-5"Nftwe`225 MDDESTO ATC RAGE 03 <br /> vvor <br /> Sen Jwquln County ErwkonrneMo$Health Servkes,Unit IV Well Permit AppllceUen Supplemenl <br /> JOB ADDRESS: /057D Sr � PERMIT SRM: <br /> S7`�Ic7a�c CA <br /> LICENSED CONTRACTORS DECLARATION { ¢) <br /> I hereby affirm that I am licensed under the provisions of Chapter a(COmmeneing with 841100M 7000) of Division <br /> 3 of the 811911"1e23 and Professions Code and my kcensa la In full force and affect- <br /> Lion se ill -7 Expiration Date, l <br /> Date_ V, oz_ Contrec <br /> Signature: <br /> ia: <br /> Printed nerve: <br /> WORKERS' COMPENSATION DECLARATION <br /> I her ,affirm under penalty of perjury one of the following declaration,, (CHECK ALL THAT APPLY) <br /> ✓i have and WIN ma;ntein a certincale of cons <br /> Section 3700 of the Labor Code.for the perfell to aNf-Insure for workers'compensation, ea provided for by <br /> ormance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performenee of the work fa whish mla permit is Moved. My workers'compensation kwurance <br /> carrier and policy numbers are <br /> Cerriu;!}]$ policy Number: [ �3 hrs' of �f <br /> cl r ify that in the performance of the work for which MM permit is!slued. I shell not employ any parson In <br /> any manner so as to become subject to the workers'compensation taws Of Cfilfomia,and agree that if I <br /> should became subject to the workers'aompensato 1110114 Of Seolion 3700 of the Labor Code, I $hall <br /> fonhweh comply With those provisions. A4E <br /> Date_�2r/_ 8lgnstura:Printed Name: tWARNING:FAILURE TO SECURE WORKERS'COMPENSARAGE IS UNLAWFUL,AND$HALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROVIDED FOR DDITION To THE COST OF I SECTION 3786 OF THE LABOPRECODE K1T6 INTEREST,AYTORNEWS FEES,AND DAMAGES A6 <br /> I' rr ` `� _ (C-s7llwnaadsuDwrixadreprwanUHw),hereby <br /> outhorraa_ s :Il,9�l6 /l11 <br /> to sign this SM"Joag3l�Cou^tyitl Permit p�pPilJ eo preon my, shah. I understand Ihls aurkoon in wild for <br /> one(1)year and Is Owned to thy work plan dstad on the front Palo of this apptleallan, <br /> fl-t?-Mc I MI <br /> - � /1 A ir. <br />