Laserfiche WebLink
14OCT. 8.2003 1 8:31AM LLHY""N L;kUUF NO.497 r'P.212 W� <br /> San JoKuin County Environmental Health Department unit IV Well P It Application Supplement <br /> r%4f— �AS(,e Ort 44 5'- /t <br /> JOB ADDRESS: Q ou e PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (L= <br /> I hereby affil atWInseder the provisions of Chapter 9(commencing with Section 7000)of Division <br /> ' C 3 of the Bu ' e ade and my liconse is in full force and effectLicense; 0Expiration Date; 9 34 2ogale: /0 - attar Signature; Title: PirC"'W ,. <br /> Printed name: ''�� ' �' T le- <br /> WORKERS'COMPENSATION DECLARATION <br /> / I hereby affirm under penalty of perjury one of the following declarationa: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self-Insure for workers' compensation,as provided for <br /> by Section 3700 of the Labor Code,for fie performance of the work for which this permit is issued. <br /> on 3700 of <br /> he <br /> K have and will <br /> of the work for which this permit tr isissuedrequiredce, as Myworkers' compensation tnoCode, <br /> insurance <br /> forthe performanc <br /> carrier and policy numbers are: <br /> Carrier: y94*6- �e.•�ne.ss�i�on �na�� ^�policy Number. G 00 '7 <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 CaRomia, 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 comply with those provisions, <br /> Date: Signature: <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 HUN0990 THOUSAND DOLLARS <br /> (6100.000.1,IN ADIN ION To THE COST <br /> V 37®OFT EF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED O <br /> AUTHORIZATION FOR DTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> I, (signature ofC-57 licensed authorizod representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my twhAlf. 1 understand this authorizatfon is valid for <br /> one(1)year and is limited to the work pian dated on the front page of this application. <br /> 6-2"7 1 MI <br />