Laserfiche WebLink
San Joaquin County Environmental Health Department Unit 1V Well Permit Application Supplemental <br /> JOB ADDRESS: IBJ�?i!n 1V, 'Tl.)ovocAuvi EA PERMIT SIR# 0d s55 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License#: 819548 Exp pate: 5-31 -2 0 0 9 <br /> Date: 9-25-2008 Contractor: TestAmerica' Drilling Corporatio <br /> Signature: Title: Regional Manager <br /> Print Name: Rick Hastings <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers'compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> xx I have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Zurich Policy Number: WC925885501 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions, <br /> f/ -� <br /> Exp.Date: 4-1 -2009 Signature: <br /> Print Name: Rick Hastings <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Rick Hastin s 14 (Signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) /! ltrr� « (5 +� to <br /> sign this San Joaquin county Well Permit Application on my behalf. 1 understand this authorization Is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> 8120/021MI <br /> EHD 29-01 W07 WELL PERMRAPP <br />