Laserfiche WebLink
San Joaquin County Environmental Health Servic23, Unit IV Well Perrllit.Applllatlon Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> UCE NSED CONTRACTORS DECLARATIONL( CDS <br /> I hereby affirm that i am licensed under the provislons of Chapter 9 (commencing with Sectlon 7000)of Division <br /> 3 of the Sus ne;ss and Professions Cada aid my licanae Is In full furca and effect. <br /> License#: U! LD �+�-7 Expiration Date: 1©t b <br /> Cate:_! . b� - rantracto, <br /> Signature: rdle: � T 1 ( �- <br /> Printed name: <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and wilt maintain a c hllicate of consent to self-7naure for workers'comparmaUon,as provided for.t►y <br /> Section 3760 of the Labor Godo,for the performance of the work for Mich 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 warn for which this permit is issued. My workers'compensation insurance ' <br /> carrier and policy numbers are: <br /> Carrier. P /r Q1 Policy Number. �C �.� 't�� � y <br /> I cxrtify that in the performance of the work for which this permit is luued, 1 shall not employ any per-ran in <br /> any manner so as to become subject to the workers'compens;ation km of Califtirr*and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cade,I shall <br /> forthwith comply with those provisions. <br /> Deft: Signature: <br /> Printed Name: <br /> WARNING:FAd-URE TO SECURE WORKERS'COMPENSAT10141 COVERAGE IS UNLAWFUL,AND SHALL 31,18JEC17 <br /> AN EMPLOYER TO CRIMINAL.PENALTI"AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (1100,000.1,IN ADDITION TO THE COSTOF COMPENSATION,INTEREST,A-FTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN 3Et:111ON 3708 OF YHE LABOR CODE <br /> >4 -0— _(C-V Hcensed autharbad nepnraentativek hereby <br /> authors )y La.0 I ✓K rrl. Vi A l -rte-e v , <br /> to sign tni*San Joaquin County Wall Permit Application on my behalf. I Understand this atAtKwiasttOn Is valid for <br /> one(1)year and LS limited to On work plan dalad on thn front pope of this 04solcation. <br /> i <br /> Z-1T-31700 t NI <br /> i <br />