Laserfiche WebLink
APR-23-2001 MON 10:35 AM GEOTRANS, INC, FAX N0, 916 3 1860 P. 02 <br /> 04-20-2001 03:40PM FR� TO 19168531860 F.03 <br /> 777 -3s7 <br /> San Joaquin County Environmental Health Services,Unit tV Well Pis It Application supplement <br /> JOB ADDRESS: 19$-O G✓� //"/Sret�T` PERMIT SR#: <br /> 7;2A,f CA <br /> LICENSED CONTRACTORS DECLARATION (,ILCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect, <br /> License#: (1, 0p� e& 5 Expiration Date: /-131 -Q 1)-- <br /> Date: ,)-1-03 -61 <br /> Date: '7 -03 -Ql Con/lr$ctor: /'-(:Sri(-1 nV 1124 n em eh� <br /> Signature: �'`i// �L� Title: )len <br /> Printed name: DJ 11,/, 01 C 14 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certNicate of consent to self-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Coda, for the performance of the work for which this permit is issued. <br /> V- have and will malnteln 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 olicy numbers are: <br /> C <br /> Carrier: 0 Policy Number. /6aCDo2QJ -U/ <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 t0 become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions off Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: � <br /> Printed Name: ,/)Ol✓l <br /> WARNING:FAILURE TO S6CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (4100,000.),IN ADDITION To THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9706 OF THE LABOR CODE. <br /> 1, -2)a1 0W /-7 S C-4 (C57 licensed authorized representative),hereby <br /> authorize ( ,&)147Ca AIS <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undamund this authorization is valid for <br /> one 1 year and l0 limited to the work plan dated on the front page of this application. <br /> i <br /> I� <br />