Laserfiche WebLink
of -04/08/2002 MON 14:06 FAX a001 <br /> San Joaquin County Eirivironmontal hlsalth Services,Unit-AV Well Permlt App n P <br /> JOS ADDRESS: PERMIT St.#: 9 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter) (commencing with Section 7000)of Division <br /> 3 of the Businre1sls1 and Professions Code and my license is in full force and effect. <br /> License#: !a0 o7 Expiration Date:q1�50/DQ <br /> Date: l L ��.,�jontractor: \/9 <br /> f <br /> Signature: f , / c Title: <br /> Printed name: �1�C1C1 A _ 1!! A 'l a _. <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 /> carrier and policy numbers are; <br /> Carrier: C a VY-1— —PolleyNumber, <br /> #certify that in the performance of the work for which this permit is issued, I shall not employ any parson 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 coply with those provisions <br /> Date: Signatur e <br /> V <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOV$AND DOLLARS <br /> M ADDITION TO,THE CAST OF COMPENSATION, INTEREST,AT'TORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I, (C-571icensed a tlOrize presentativej, her b <br /> authorize ' 1�( <br /> to sign this San Jeaquin County Well PermitApplicat on on my behalf. I understand this authorization is valid fof <br /> one(1)year and is firnitad to the work plan dated on the front page of this application. <br /> . i I'IUd� 1'JtY�S'C7 l E-if=,Fi l• D0—C'71 <br />