Laserfiche WebLink
OCT. 14.2003 9:44AM NO.515 P.2i2 <br /> FJO <br /> en JoagwIn County Enuirronmentaf H Department Unft IV Well permit Applleeidon 8uptffemeltt <br /> Aaal ss:A IN, PGRIUIT SAW: . 6 35 <br /> LICIENSED CONTRACTORS DECLAMATION (= <br /> I hereby affrontr r qc <br /> 2 sod under the provlrions or Chapter 0(commencing witn aectlon 7000)pf PMWpn <br /> Sof the Bunt 16 and f one Code and my 11cense is in full force and a eat. <br /> 69597 Cxpiratfon Date; 9-30-20Q4 <br /> bets: 'Qua er 14 2003 Oontraoto ; Environmental co��ol A&goci„ro '-� —. —_� <br /> ,.�.�_ <br /> 8ipnatuce: Tltla: President <br /> PrFniad normo! Tifnothy B. vier <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby efllnn under penalty of penury one of the following declarations: (CHECK ONE) <br /> 1 nave snd will maintain 0 QW111090 of aorment t0 saif4nsune forworkers'compenaoNon,OR provided far <br /> by 540tlon 3700 of the Lapor Cade,for the performance of the work for which this permit Is Issued. <br /> ,J,I have and will maintain workers'compensation insurance, as requlrAd by 3@cHon 3708 of the Labor Code, <br /> for the pelrfomlanoa of the work fbi-which this permit Is issued. My wonkam'campenaation insuranm <br /> carrier and policy numper3 are., <br /> Carder. State Compensation Insurance FPttrfrcy Number.-1U_161QQJ•03 <br /> 1 Oertlfy that In Vie performance of the work for which this permit 18 issued, I shall not employ any pmn to <br /> any Manner so as to MOM®Ubleet to the workers'compensation laws of Calillimia,and opts@ that If 1 <br /> should 08come subject to the workers'compensation provisions of SWUM 9700 of tha Labor Code, I shall <br /> fvltllmMth wply WIM those provisions. <br /> am; � Signature: <br /> Pfintad Name: <br /> WARNING:FAILURE TO SECURE WORr(ERS'COMPENSATION CMRAot:Ie UNLAWFUL,AND SHALL.RUBJECT <br /> AN EMPLQYR`li TQ CRIMINAL.PENALTIES AND CMI.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,00o.,IN ADDITION TO Tt1E COST OF GTTOR ere <br /> OMPENGATION,INTEREOT,AFEES,AND DAMA13ES AS <br /> PROVIDER FOR IN 311MMON 3700 OF THE LABOR CODE, <br /> AUTHORIZATION FOR THAN C"67 311131NING PERMIT APPLICATION <br /> 10 (glpnaturs BMW IlWased at"Odad mprspnpoft), <br /> heraby 4 twee(piing names.._ <br /> to salon this elan Joaquin Counly Well Persalt Applkation an my behalf. I undsnotantl this autller UHan Is valid ror <br /> one(1)year and is rhnited to the Werk pian d~on the front pegs of this application. <br /> 8-28-02 l Nil <br />