Laserfiche WebLink
San Joaquin County Environmental Health Dep rtment Unit IV Well Permit Application element <br /> JOB ADDRESS: 12- <br /> �/DOO Lti, 1Jj%W /45f PERMIT SR#:4ODp�/0 <br /> LICENSED CONTRACTORS DECLARATION (L <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 full force and effect. <br /> L-cense ti v �' .�3 K Expiration Date: <br /> I <br /> IDate Contractor 4^^'p�� <br /> Signature: CL].:L��r-- Title: �� �4•r. t /Vn O <br /> Printed name: Lie.., InJ' ,.Jw.. r 'DiqJA WIN&LeWIC-4 <br /> d <br /> WORKERS' COMPENSATION 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-insure for workers'compensation,as provided for <br /> by Section 3700 of[tie Labor Code,for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance,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 <br /> numbers ire: <br /> Carrier: G unrj Policy Number:_00455,3-) <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 <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 /> Expiration Date;`L O Signature:^1 <br /> Printed Name: �•--a Lv:Mltw _�� <br /> U <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-57 SIGNING PERMIT APPLICATION <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <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 /> 0-29-021 MI <br /> Hilt N•02(VII <br /> :2:n: <br /> 7 'd R74,7-Rqq InFGt 2UTITSJD Isd eTE :60 90 BZ 09U <br />