Laserfiche WebLink
FROM, :Re&'onantSonicInternational FAX NO. :5306682429 {^ �'ar. 25 2004 11:47RM P4 <br /> 01/25/04 TRU 10:32 PAX 825 963 7275 VRRA VAC NOR CAL [it oaS <br /> San Joaquin County Environmental Health Oepartrrlent Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: -7 6'-(j Q&c.tfle„ 14ve-t9*o,.k*r t. PERMIT SR#• OD3 -72- <br /> LICENSED <br /> LICENSED CONTRACTORS OECLARATION (LCE]) <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 Cade end my license is in full force and affecctt. <br /> License#: ,`! � �� Expiration Date; [ �c�r f~ S> <br /> Date: �l �J `7 CCntractor:� �C_ N.,� <br /> 1 <br /> Signature:� -Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DIECLARATION <br /> I he (firm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> !� Ie and will maintain a certificate of consent to self-insure for workers'com e <br /> p nsaUon, at provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit Is issued, <br /> gave and will maintain workers'compensation insurance, as roquired by Section 3700 of the labor Code, <br /> for the performance or the work for which this permit is issued. My workers'compensation ompensation insurrance <br /> carrier and policy numbers are: <br /> Carrier: Policy Number: w✓ ` <br /> certify that in tho performance of the work for which this permit is issued. I shall not employ any person in <br /> eny manner so as to become subject to the workers' compensation laws., of California, arrd agree that if I <br /> should become subject to the worker:' compensation provisions of Se6nn 3700 of the Labor Code, 1 shall <br /> forthwith cnmply with these provisions. <br /> Expiration Date: _LPAAA-PT Signature: ` <br /> Printed Name:... <br /> I WARNING';; FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL-,AND SMALL 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,ATfORNFY'S FEES,AND DAMAGES A5 <br /> PROVIDED FOR 1N SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTI'-(ER THAN C-57 SIGNING PERMIT APPLICATION <br /> ofC-57 licensed authorized representative), <br /> hereby authorize(print n9me) W <br /> to Sign This San Joaquin County Walt Permit Application an my behalf. I understand this authorization Is valid for <br /> If one(1)year and Jr.limited to the work plan dated on the front page of this application, <br /> B-29-02 1 MI <br /> i-.i�t1 zy-ts�-oar <br />