Laserfiche WebLink
? i <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: -z8sQ L oM is F .R PERMIT SR#: <br /> S7 o C-1C.0,J C <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 f ill force and effect. <br /> License#: C S — Vo ZZ !!Expiration Date: o� nl ov bq. <br /> Date: SIA Zot A Contractor;': dv 4LF Q & <br /> �V I'o In T, <br /> Signature: Title: <br /> Printed name: o F MAAT- <br /> WORKERS' COMPENSATI N DECLARATION <br /> I hereby affirm under penalty of perjury one;of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-in ure for workers' compensation, as provided for <br /> by Section 3700 of the Labor Code, forjthe performance c f the work for which this permit is issued. <br /> XI have and will maintain workers' compensation insuranc , 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: reg <br /> Carrier: CA ��• 1 Policy Number: _UA33 V 3 9S6 U <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'jcompensatio pro i 'ons of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions.il <br /> Expiration Date: 10,71 ILQ 10 Signature: <br /> Printed Name: R a bFr" F- M4.4-T <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 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 /> AUTHORIZATION FOR OTHER THAN C-5 SIGNING PERMIT APPLICATION <br /> I, LEr >< "SART—I _ (signature ofC-57 licensed authorized representative), <br /> y <br /> hereby authorize (print name) J CVS <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 plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EHD 29-02-001 <br /> 6)'))/14 <br />