Laserfiche WebLink
08/01/2000 09:07 2094683433 FIFTH FLOOR PAGE 03 <br /> San Joaquin County Environmental HealWServices, Unit IV Well Permit Application Supplement <br /> c1} � <br /> JOB ADDRESS: SS J:�eJIW� , 22c " PERMIT SR#: 0 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 /> 11 <br /> License �j n Expiration Date: 061 nuC <br /> — < <br /> #: -, IIJ� <br /> D <br /> L - ntract <br /> Date: <br /> r: <br /> Signature: Title: <br /> Printed name: �T <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> -insure for <br /> 6-" I have and will 0 fmaintain a certificate of consent to <br /> he Labor Code for the performance workers' <br /> of the work fowhch this permits issuedvided for by <br /> Section 3700 <br /> I have and will maintain workers' compensation insurance, as requiWorkers'd by Section <br /> 3700 of the insuranceorCode, <br /> for the performance of the work for which this permit is issued. My P <br /> carrier and policy numbers are: e <br /> Carrier: Policy Number: <br /> lJ <br /> I 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 I <br /> should become subject to the workers' compensation provision Section 77e Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: '���� Signature: <br /> Printed Name: S <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> ES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> AN EMPLOYER <br /> ATDD 7 ON <br /> IITO THE COST OF COMPENSATO <br /> ION INTE ES7 ATTORNEY SFEES,AND D MAGES AS <br /> ($100,000.), <br /> PROVIDED FOR IN 1SECTION 3706 OF THE LABOR CODE. <br /> J /S (C-57 licensed authorized representative),hereby <br /> authorize—/9 T <br /> rmit Application on my behalf. I understand this authorization is valid for <br /> to sign this San Joaquin County Well Pe <br /> one(1)year and is limited to the work Dian dated on the front page of this application. <br />