Laserfiche WebLink
11/03/2004 12: 27 9166385671 CASCADEDRILLIN6 PAGE 03/03 <br /> San Joaquin County Environmental Health Department Unit Rf Well Permit Application Supplement <br /> JOB ADDRESS: i C z. S fl PERMIT SR#: 0040 -30q <br /> Corp <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 and my license is in full force and effect. r <br /> License# C52 - 11 ? I O Expiration Date: <br /> f <br /> Date: I I ' 3' 0 cont tor: <br /> Signature; Title:— i ! V <br /> printed name• <br /> WORKERS' COMPENSATION DECLARATIPN <br /> I hereby affirm under penalty of perjury one of the following declaratians: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure forworkers'compensation, as provided for <br /> by Section 3700 of the 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 37UU of the Labor Code, <br /> for the performance of tho work for which this pormit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: I <br /> Carrier: _Policy Number. <br /> 1 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 1 <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: S' I 'C) Signature: <br /> Printed Name: O <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 /> 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 /> AU HORIZAT ON FPR 0 THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC-57 licensed author;xed representative), <br /> hereby authorize(print H0,L(11 66 ifi6, Z LLLS <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 pago of this application. <br /> 29-021 MI <br /> EMD 29-02-001 <br /> 0170!711!1 <br />