Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: �/ PERMIT SR#: 04 t <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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 /> f License#: C.~5 lS Zao <br /> 4' expiration Date: S5 <br /> Date: 7 � Contractor: AJ 1 L S <br /> ��"= Signature �:� - - �••�„�- - =�� -'�Y--'��= �: --�:�. ~<��y -- - _� .. .... ��::.���:�.� <br /> • ._ =� - Tale: - �� <br /> Printed name: C, <br /> WORKERS' COMPENSATION DECLARATION f <br /> C 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-insure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. l <br /> Ihave and will maintain workers'compensation irisurance, as required by Section 3700 of the Labor Cotte, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance I <br /> carrier and policy numbers are: t <br /> Carrier: .-*ATC T Policy Number: [i- OL-30 q <br /> 1 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 <br /> should become subject to the workers'compensation provisions of Section 3700 of the'Labor Cotte, I shalt <br /> forthwith comply with those.provisions. <br /> Expiration Date:21461&6Signature: <br /> Printed Name: <br /> ms=s= <br /> WARNING: FAILURE TO URE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ,($100,000.),IN ADDITION TO THE COST OF-COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING 'PERMIT APPLICATION <br /> (signature o(C-57 licensed authorized representative), i <br /> hereby authorix (print name) A <br /> to sign this Sara Joaquin County Well Permit Application on:,my behalf. I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EMD 29-02-001 <br /> N�9t(1� <br /> u <br />