Laserfiche WebLink
02/20/2001 TUE 14:26 FAX 916 4101 F IVD,FILLIN�, INC <br /> • 0 002 <br /> San Joaquin County Environment -Health Serxicee,Unit=IV.WuIltPermit ApFilaation••SU went <br /> 002�y <br /> ew <br /> JOBADDRESS'� W- ^ pERMYf', SC29. �r <br /> .QO MJ <br /> LI ENSEE) ONTRACTORS DECLARATION (LCI)) <br /> 1 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 /> license S <br /> !U (��� Expiration Date' �� <br /> ?� D/ ontractor: Va V �C <br /> Title: <br /> Signature: <br /> Printed name: ! . <br /> / WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and Will maintain a certificate of consent to self-insure for workers' compensation, as Provided for by <br /> Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> ction 3700 of the <br /> ✓fort he performanceitain of the work for which this permit ion r snissu d My works s'compensat'on insurance ode, <br /> carrier and policy numbers are: <br /> tJ-1 aG�e -- <br /> Polley Number. <br /> Carrier: <br /> _I certify that in the performance of the work for which this permit is issued, t 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 I <br /> should become suoject 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 HUNDRED THpUSAND DOLLARS <br /> IN ADDIT)ON TO HE COST OF <br /> THE LABOR COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR N SECTION <br /> p C47 ileermed author ad rep rrtAUve},hereby <br /> authorize `i� v <br /> to sign this San Joaquin County Well Permit Application on my behalf. I undemtand this authoraation Is valid for <br /> aPPIiC8dOn. <br /> one it l year and is limited to the workplan dated on the front page of this <br /> wpH� wtr9S°0 L 6661—ro0-0 L <br /> �"d <br />