Laserfiche WebLink
04/?3/2004 14:27 209*433 FIFTH FLOOR PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> jJOB ADDRESS: 3CoA2) Du�'IZ Ndd k�� ( PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License#: ei 7— 7 1 -7 i 1 O Expiration Date: —o U <br /> Date: — L4 Co Aactor :1)S--1 1 n A <br /> Signature• Title:Title:Printed name: V <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation,as provided for <br /> by Section 3700 of the Labor Code, for the performance 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 performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy Inumbetrs are: <br /> Carrier: A6'NI\ \ I\�Q_1_, Po)icyNumber:�� <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in . <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should became subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> _ forthwith comply with those provisions. <br /> Date:_r'l�� � Signature: <br /> Printed Name: P /—Gl C ri, R/rV--,� a' <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> ALITH AT10N OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> p (signature ofC57 licensed authorized representativ ) <br /> e <br /> hereby authorize(print ) �n ` ( <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 this application. <br /> 8-29-02!MI J <br />