Laserfiche WebLink
2008-05-19 09:03 WDC RI WOA7L7CA 1 >> 9259442859 P 2/2 <br /> Z/Z d KMIU DGM << 698Zb665Z6 • 99600 95LOT ST-SO-80 <br /> San Joaquin County Environmental Health Department unit IV Well permit Application7Suppiemental <br /> JOB ADDRE6s: <br /> PERMIT SR# <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 /> Division 3 of the Business and Professions Cade and my license is in full force and effect. ) <br /> License*- 2-Mx6 Exp Date: (P�3n zpvQ3 <br /> Date: 16 x008 Contractor WDC ! �pYa�70y <br /> --- - <br /> Signature: Title: P/d r7J7lYL1�DY!$ /(/lam <br /> Print Name: hYi 7a7VM � <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following dedaratlons: (check one) <br /> z t have and will maintain a certificate of consent to selfinsure for workersCompensation, a$ <br /> Provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> Permit is issued. <br /> I have and will maintain workers'Campersation 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 /> Carrler:x1106h CuY/I IT. 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 Code, i shall forthwith comply with those provisions, <br /> Exp. Date:—A d 1 2V0 Signatttre: <br /> Print Name: CihnE' Ta*q? <br /> WARNING:FAILURE TO SECURE WORKERS•COMPENSATION COVERAGE LS UNLAWFUL,AND SHALL$USJECT AN EMPL <br /> CRIMINAL PENALTIES AND CVVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,OYER TO <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> RIZATIOIV F9R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> hereby authorize(print name) (signature of C-57 licensed authorized representative), <br /> 119 <br /> C/� 7y}'J7JM <br /> Sign this San Joaquin county Well Permit Application on my behalf, I understand this <br /> authorization is <br /> for one year and Is limited to the work plan dated on the front page of this application, valid <br /> NI2vn2Ml <br /> EHp P80f i1f5p7 <br /> Y��L FEPMlf 4vp <br /> ZB .Mvcl esl GSBZV069ZG LB:OT B99Z/9T/QA <br />