Laserfiche WebLink
Nov 25 03 04t11P Horizon Env. -Inc 916 939 2172 P•2 <br /> Sen jawin County Ertvi*orrmentel"00th t)epartmen Wall Permit Applicedon Supplemaftt <br /> .LOQ ADDRESS: 39 {s 1'Ei41`�?OT <br /> :L <br /> Ll <br /> 3 <br /> LIC P�OPdTRACTORSDEC.LARATIDM ILCD) <br /> F hereby affirm that I am licensee under.(ho provimona of Chapiet.g(cornmeWing�n 7400)_Of��n <br /> _31f�he�nsiness andi>rofessions Code and my license is in full force and effect, <br /> License <br /> Date: r / con cloy: �t�Yy+� – <br /> slgnature: Tae:_ <br /> Pointed name: t.rf►/.�,r� ��/"' <br /> 47 <br /> WORKERS, COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations- (CHECK ONE) <br /> 1 have and will maintain a certi6ra.to of consont to eolf-inaure for workers'compensation,as provided for <br /> by Section 3700 of the Labor Code,for the performarice-of-tho far,.whicFr (;s; d <br /> _X(f have and will maintain workers'Compensation insurance,as►eslulrr�gy.Section 3701)of the Labor Code, <br /> for <br /> carrier <br /> and policy <br /> numbers <br /> aorklotwhichthis Fermis is issued. My workers'compensation insurance <br /> carrier and policy riumbens are: <br /> Carrier: 4 S/7'7 policy Number: #"–_V g';,;P(V— <br /> I certify that in the performance of the work for whmh this permit Is issued,I shall not employ any person in <br /> any manner so as to become subject to the workers'compensationlaws.of Califomia,and agree that if I <br /> Should become-subjeCtI0 the workers compensation provislons of Seetion 3700 of the labor Code.I shall <br /> forthwith comply with those provisions. <br /> Date: ' /0 Signature: <br /> Printed Name: <br /> OF <br /> f E TOS URE WORKERS'CDWEUSATION COVERAGE IS UNLArIFUL.ANn smALL SUBJECT <br /> AN EMPLOYER To CPJMJNAL PBNALTICS AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.1 IN ADDITION TO THE COST.OF rOMpFtSATION,49TRAEST.-ArIT y8 $�A ND DAMA S AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AtiTwORlzA'rtoNFORAll C-37 SIGRIING PERMIT APPLICATION <br /> f8ignature ofC-67licensed authorized reproaentativel, <br /> horeby authorize(print name L� <br /> to Sign Ims San Joaquln County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(1)yearand is lieaited to the work plan dated on the front page of thio application. <br /> '0.2942 r All <br /> f= -d <br /> 0026 13Cd3SW1 dH WdOS :9 0002 S2 AOW <br />