Laserfiche WebLink
Received Fax; 12/16108 02.39FRox Station; A11 Vel; kbandokent p.02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> f� <br /> JOB ADDRESS: 355 ENTERPRISE PLACE, TRACY PERMIT $R#; <br /> LICENSED CONTRACTORS CiECLARATION LCD <br /> Ez <br /> I hereby affirm that I am licensed under the provisions of Charter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is In 11 ill force and effect, <br /> s 0 <br /> Llcense A IA23S Expiration pate; <br /> Date: Contractor: ALL WELL AN,NDONMENT'� <br /> Signature: �`` Title; �� f <br /> Print name <br /> .I <br /> WORKERS' COMPENSATIC'1N DECLARATION <br /> , <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-inrsuto for workers' cop Sensation, as provided for <br /> by Section 3700 of the Labor Code,for the performance.)f the workfor which this permit is issued. <br /> F <br /> I have and will maintain workers'compensation insurano,,as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is is aced. 0 y workers' compensation insurance <br /> carrier and policy numbers are: <br /> � �--- ' <br /> Cartier. palls} Number;'' -"00 1 7 OM <br /> E�- <br /> I certify that in the performance of the work for which thLs 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 become subject to the workers'compensation provisictps of Stiction 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. �✓'~' it <br /> Expiration Date: JD-1, Signature: <br /> POnted Name; <br /> F <br /> WARNING' FAILURE TO SECURE- ORKERS'COMPENSATIOI I COVERAGE to UNLAWrUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL.PENALTIES AND CIVIL FINES UP TO ONE HUNDRE©THOUSAND DOLLARS <br /> 136NWW 6 IN ADDITION TO THE COST OF COMPENSATION,1VTEfiEST,-ATTORNE Vs )Ems,AND DAMAGES A5 <br /> PROVIDED FOR IN SECTION PM OF TILE LABOR CODE„ ' <br /> �6 <br /> AUTHORIZATION FOR (?TNER THAN C-57 SIGNING PERMIT APPLICATION <br /> / � <br /> E:tgnatur+e ofC-Rr llcensed authorized representative), <br /> i <br /> hereby authorim(print name).__ Ally colavita ,(„Advanc <br /> 3 <br /> to sign this Sari Joaquin County Well Permit Application on rm;r behalf l understand this authorization is valid for <br /> one EM year and Is limited to the work plan dated on the front t age of this application„ <br /> U-M-fl /MI <br />