Laserfiche WebLink
02/20/2001 TUE 14:26 FAX 916 7Z 4101 V N DR;LLING INC • 002 <br /> San Joaquin County Environment I-liealth S.ewlces,Unit IV We UPermit•Appileation•Su Ment <br /> oozsa� <br /> JOB ADDRESS: PERM <br /> / eS <br /> LICENSED ONTRACTORS DECLARATION (LCD) <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 <br /> i and Professions Code and my license is In full force and effect. <br /> 7 <br /> License#: vA Expiration Date: <br /> Date; Z D� - ontmeor: <br /> Signature: Title: L`,li� <br /> Printed name: j0 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury Ono of the fallowing 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 /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> T for the performance of the work far which this permit is issued- My workers compensation insurance <br /> carrier and policy numbers are: <br /> n <br /> Carrier: l FCoic' Policy Number: <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 subject 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 18 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THpUSAND DOLLARS <br /> (5700,OD0.), 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 /> 4C-87 Ilcensed author ad repmative), hereby <br /> authorizelxe If' l- W <br /> to sign this San Joaquin County Well Permit Application on my behalf. 1 understand this authorization Is valid for <br /> one(f)year and is limited to the work plan dated on the front page Gf this application. <br /> g -d WDb� wv95'0l 6661—ro0-81 <br />