Laserfiche WebLink
No. 9661 <br /> Nov. ?0, 2009 10:02AM <br /> v v ' <br /> I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: %,SSS HavnWte SFo LPERMIT 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 Code and my license is in full force and effect. <br /> License Exp Date: <br /> ILI <br /> Date: Contractor: C Q yy t `f yi <br /> Signature: <br /> Print Name: Ctirt ��� �Y1lnE'� <br /> WORKER'S COMPENSATION DECLARATION <br /> I <br /> 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this h <br /> permit is issued. <br /> _I 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: % E(o <br /> I <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 provision <br /> Exp. Date: a I Signature: <br /> Print Name: Ctirli 1�\"F 1 v tt✓)E/ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> ZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to Ar+�R to <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 /> 3MMUTAl <br /> EHD 28-01 111607 WELL PERMIT PPP <br />