Laserfiche WebLink
r <br /> San Joaquin County Errviranntental Health Departrmnt Unit IV Well Pern*Application Supplement <br /> JOB ADDRESS: P-- e—Mg55 N, - {) "A PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commeWrig with Section 7000)of 10lrision <br /> 3 of the Business--and Professions Cade and my license Is in full force and e <br /> License#: :T-Z&l E*Iratian Date: L�- 3 0 <br /> Date: <br /> Slgnature: 1.a, Tilde: rs <br /> Print*4 name: <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following dec larat;ons: (CHECK ONE) <br /> I stairs and will maintain a certificate of consent to dalfwinsure for workers'compensation,as provided for <br /> by Section 3760 Cr the Labor Crile,for the perforrnenc a of the work for which this permit is issued. <br /> I have and will maintain workeis'compensation insurance,as required by Section 3700 of the Labor Code, <br /> far the performance of the worts for which oris permit Is Issued. My wor kers'COmpensation insurance <br /> carrier and policy numbers arts: <br /> Carrier: �l Policy Nurt:ber:, (30S— „1 SSA fQ .� <br /> I cartify that in the performance of the work 4r whO this permit is Issued, I shall riot employ any peon in <br /> any manner so as to become subject to the viorSce'compensation laws of Catiforria,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Cade,i shall <br /> k thwith comply with those provisions. <br /> Expiration Date- Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSAMON COVERAGE IS UNLAWFUL,AND SMALL SUBJECT <br /> AN EMPLOYER TO CFUVIIHAL PENALTIES AND CML FINES up 7o ONE HUNORER THOUSAND DOLLARS <br /> ($100,000110 A=TION TO THE COOT OF COMIpMATION,INTEREST,A7Tt]ttl► y"a FEES,AND DAMAGES AS <br /> PROVOED FOR IN SECTION 3706 OF THE LAWR HCOOS <br /> -AUT fO,l IZATION FOR CHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, _ 'w-4I-Jvli 4balkir' ori fM(signature ofC-67 licensed authorized representatheo), <br /> hemby au thorim(print name} t�. W, d n -/ <br /> to atgn this San Joaquin County Well Permit Application on my behalf. I understand this authorization In valid for <br /> one(1)yew and is limited to th*work plan dated on the from page of this application. <br /> 8-2"2 J L2 <br /> EM 39-M-001 <br /> 6=104 <br />