Laserfiche WebLink
1 <br />( Pr;%�1i1"/21/2008 15: 2.5 92552 ',t94 VIRONEx SF � PAGE 01 , <br /> ff 11 No 5996 P - 4 <br /> Nov .21 2008 1 :06PM W ht Envir omental B32 5152 <br /> C9 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appliccatio�n/Supplemental <br /> JOB ADDRESS: JrCI 5 PERMl7 SR# _ 054 <br /> r <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)Of <br /> i <br /> Divlsion 3 of the Business and Professions Code and my license is In full force and effect. <br /> License#: 7 OS9 a� ___Exp Date: 5' 31 09 4`` <br /> Date: v Contractor: �,1rQ�� <br /> I:(M-�C�' <br /> Signature: Title: <br /> Print Name: <br /> WORKER'S COMPENSATION.DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> V I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> l have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier. Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I Shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Cade, I shall forthwith comply with those provisions. <br /> Exp. Date: 6 I' l ak.0>t . Signature: <br /> uAkP Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SMALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL PINES UP To 0100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> .ATTORNEY'S FEES,AND DAMAGES A9 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> UTHORIZA N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> G - (signature of <br /> C-57 licensed authorized representative), <br /> ( UpCtCL �/ <br /> hereby authorize(print name) __CW Ct <br /> QUI 20/1MQ/T}F.Q ,t0 <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization Is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> MA709/MI <br /> WDLL PCRMITAPP <br />