Laserfiche WebLink
02/22/2006 09: 10 FAX qv° eO, "'" '� • <br /> • a-�- T� � o b <br /> Application Supplement <br /> F3of <br /> Joaquin County Epvironmontal Health Department Unit IV Well Permit App ' ( D 3 <br /> 1t,, , 1954, ItI[LD AVE - PERMIT SR#: �D L <br /> ADDRESS: 616 ots z t CA 4S2o 3 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> by aMrm that I am licensed under the provisions of chapter 9(commencing with Section 7000)of Division <br /> e Business and Professions Code and my license is in full force and effect. <br /> License ZF: a� Expiration Date: <br /> h <br /> � r <br /> z o Contractor: <br /> pate: - <br /> 9lgnature: Title: <br /> Print name- y( " <br /> WORKERS- COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> a certificate of consent to welf-insure for workers' com , a <br /> ,,�l have and will mainin <br /> sation <br /> by Section 3700 of theta <br /> hhe Labor Code, for he performance of the work for which th snperm t isissued.ed for <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 numbers are: <br /> carrier: <br /> A, Policy Number <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 become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: Signature'— <br /> Printed Name: <br /> WARNING:FAILURE FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLSUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100 000.).IN ADDITION TO THE PST OF COMPENSATION, <br /> NSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> ROVIDED FOR N SECTION 3706 F <br /> 4hemby, <br /> HORIZATION OTHE/THAN C-57 SIGNING PERMIT APPLICATION <br /> �r—F� signature ofC-67 licensed authorized representative), <br /> orize(printname) L I <br /> to slun this San Joaquin County Well Pennit Application on my behalf. I understand this authorizatlon is valid for <br /> one(t)year and Is limited to the work plan dated on the front page of this application- <br /> B-29-021 <br /> pplication.B-29-02t MI <br /> EHD 29-02401 <br /> AMIN <br /> z •d 62ia-899 (OES) 2C? ITIJO I621 d90 :aT 90 as qaj <br />