Laserfiche WebLink
FROM West Hazmat FAX NO. 19166388613 May. 15 2008 10:48AN P1 <br /> 05/15/2000 09: 37 20946L 33 FIFTH FLOOR PAGF 02 <br /> :..: <br /> s 'rJiohl µr !:, wuny Enirll�ninelptat Mii±alth rrrut A ,PI � tiali'�5rgs �ttllltl ;: <br /> i•- <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provlsion� 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 affect. <br /> License#: SS' `I 7 9 Expifation bate: J A-0 31 zoo l <br /> Contractor; ivtnr t �-�^rt�� ZrL&,A1 � ► <br /> Signature: Title: �di�• . C'�rvr �3,6��t *-a"� <br /> Printed name; fid. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by f <br /> �..Section 3700 of the Labor Code, for the performance of the work for which this permit is issued_ <br /> have and will maintain workers' compensation insurance, as required by Section 3700 of the labor Code, <br /> for the performance of the work Far which this permit is issued. My workers'Compensation Insurance <br /> carrier and policy numbers are' <br /> Carrier: Policy Number: U at 28Z-X-0.2,7 !21 <br /> __,eKCertlfy that in the performance of the Work for which this permit is isr&ued, I shall not employ any person In <br /> any manner so as to bcacome subject to the workers' compensation laws of California, and agree that if I <br /> should becomra subject to the workers' compensation provisions of Section 3700 of the labor Codes 1 shall <br /> forthwith comply with those provisions. <br /> Vato: n -��'"a a Signature: <br /> Printed Name: `moi �.�srw.4A i0h <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18' UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,040.), IN ADDITION TO THI.COST Or COMP15NSATION,INTF,REST, ATTORNEY'S rEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. <br /> A/ d''" � (Cd7 licensed authorized reprosentaative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization i6 valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br />