Laserfiche WebLink
bee 09:52 2094683433 <br /> lth'Services, Unit IV Well Permit APP 10 <br /> Supplement <br /> San Joaquin County Environmental H" PERMIT SR#= <br /> JOB ADDRESS: ' S'rC�- �vn C._ ana- <br /> LICI=NSED CONTRACTORS DECLARATION (LCD) <br /> m that I am licensed under the provisions of Chapter full forceomm effectg.with Section 7000)of Division <br /> I hereby affirm 1+cense <br /> 3 of the Business and Professions Code and mY <br /> Expiration [Date-- <br /> License <br /> Date:License#= <br /> Contractor <br /> Date: [-,2 -- <br /> Title:_�. -L�.+�- J <br /> Signature: <br /> Printed name: <br /> WORKERS' CpMpENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK Al-L THAT APPLY) <br /> _ and will maintain a certificate of consent <br /> of the work fot to self-insure for wor which this permit is issued. <br /> rkers' compensation, as provided r Y <br /> !have <br /> Section 3700 of the Labor Code, for the performance <br /> red by Section <br /> 0 of <br /> 1 have and will maintain workers' compensation insurance,as. My workers'' rompenstationinsura insurance ode, <br /> for the performance of the work for which this permit is issued. Y <br /> carrier and policy numbers are <br /> , ,\ \�� C� Policy Number: ",� �1 S <br /> Carrier:yr to an person in <br /> certify that in the perfit is issued, <br /> ormance of the work(workers, chich ompensation laws of California.land <br /> agree <br /> that <br /> lif I <br /> s perm <br /> I ce �' <br /> any manner so as to become subject to the ensation provisions of Section 3700 of t <br /> ShO <br /> should become subjectto the <br /> workers <br /> comp <br /> forthwith Comply with those provisions. <br /> Signature: <br /> Date: <br /> printed Name <br /> SUP 70 ONE HUNDRED YHOUSAND CCLLLAR GES AS <br /> WARNING: FAILURE TAND O SECURE WORK COMPENSATION COVERAGE 1S UNLAWFUL,AND SHALL SUBJECT <br /> qN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES <br /> IN ADDITION TO THE COST OF COMPENSATION, <br /> ON,INTEREST,ATTORNEY S FEES, <br /> ($100,000.), <br /> PROVIDED FOR IN SECTION 3706 OF representative),hereby <br /> (C-57 licensed authorized rep <br /> J <br /> authorize n <br /> Well Permit Application on my behalf. I understand this authorization is validv <br /> to sign this San Joaquin County lication. <br /> one(f)year and is limited to the work plan dated on the front page of this app <br />