Laserfiche WebLink
i <br /> 05/04/2004 08:50 20946_ 3 FIFTH FLOOR �I PAGE ` 02 <br /> II � <br /> i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appiication Supplement <br /> JOB ADDRESS: ) 5600 Yi Ar 4J- PERMIT SR#: i! <br /> Lad'hr-a�P <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed underthe 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 efTeCL <br /> License#Cr g5 1 1O S Expiration Date: <br /> Date <br /> Signature: JJ Title: P <br /> Printed name: i' AMII io9GQ Q� <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (CHECK ONE) <br /> _1 haire 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 peimit is Issued. <br /> �l have and'wlll maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, - <br /> }or the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: IWZAr . Policy Number: 7.*+W <br /> I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in r. <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 provision o(Se tion 3700 of the Labor Cade,I shall f <br /> forthwith complywith those provisions. <br /> Expiration Daterx—fi y_,-Signature: <br /> Printed Name: Jor- <br /> WARNING:FAILURE TO SECURE WORKERS•COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEOr I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS j <br /> (1110,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, <br /> AUTH I TIO OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, NGBiL_ ((signature oIC-67 licensed au <br /> Uiodxed represenfalivel, <br /> hereby authorize(printname) 542t e—, CAri -.� - <br /> to sign this tsn Joaquin County Well Pemtit•Application on my behalf. I understand this autlind2adon is valid for <br /> one(t)year and is limited to the work plan waled on the front page of this 4pPliea4on. <br /> 8.29.021 MI <br /> 950/2002 <br /> i <br /> E 'd OOZE 13ra3SH-1 dH WH80t01 100.2 40 AHW <br />