Laserfiche WebLink
t 02/06/2001 08:44 20946715 AGE STOCKTON • PAGE 02/02 <br /> San Joaquin County E]nvironmen al ealth Services, Unit IV Well Permit Application Su plement <br /> / <br /> JOB ADDRESS: "{ r 1 PERMIT SR#: DOz <br /> fit , C <br /> LICEN ED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that t 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 /> License#: Expiration <br /> •�D/ate: <br /> Date: b Q Contractor: <br /> Signature: Title: <br /> Printed name: OS <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 <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued, <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> cameran polic numbersare, LA� <br /> Carrier: AL - Policy Number* ( tel I'L`VL/ <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 provisions of Section 3700 of the Labor Code, I shall <br /> forthwith compiywfth those provisions. <br /> Date: . Signature: <br /> Printed Name: <br /> WARNING. FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS. <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND.DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, (C-57 licensed authorized representative), hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and Is limited to the work plandated on the front page of this application. <br /> 5-17-2000 I MI <br />