Laserfiche WebLink
J.726i2FI 1cc.';:+ a1I"8"17d :r_i: c,•>r,I. L'_r't,:� <br /> `4e e ' a'y,lu PIS ,I <br /> 'CUvl-G S <br /> '(/�2- 3 Z `� JLC" <br /> San Joaquin County Environmental Health Departmennt/Unit IV Well PrrmR A.Ppfication Supplsmeni l <br /> J09 AOORirsS:_` 3/9 ��L . .PERMIT SR#: D0733� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I h3reby affirm that I am licensed under thr provisions of Chapter9(Con nancing with Section 70001,of Division <br /> 3 of the Busin�elss aan}o Professi ns Conn.and my license in in full force in1)d ffect. I <br /> License : I p0 � 'EI„'planonDate; <br /> Darr: _Contract"-to <br /> W � <br /> NT— <br /> Signature:_ 71t1a: <br /> Printed name: Q <br /> WORKERS' COMPENSATI DECLARA110N <br /> I hwaby affirm undar penalty of perjury ane of the following declarations; (CHECK ONE) <br /> `I I'Lave and will maintain a confcata of consent to selRinsura for workers' compensation, as provided for <br /> by Section 3700 of the Labor Cado, for the performance of the work forwhich thl-3 permit Is issued. <br /> I hsve and will maintain workars'cornpensation Insurance,as required by Section 37CC of the I nbor Code, <br /> for the performance of the work for which this pem•Iit is issurd, My workers'oompancatk:n Insurancc <br /> carrier an, policy numbs aro: <br /> Carrier: C' ,' �G Palley Number: <br /> I ceiriry that in tho performance of the work for which this permit is issued, I shail not employ any person jr, <br /> any man nor to as to become sublact to the workers'compensation lawn,of California, and ogres that if I <br /> should bo=na subject to the workers'compersa ion provision* of$niton$700 of the Labor Cede, I shall <br /> forthwith comply Win thane provisions. <br /> Dote:_., ,Signature., <br /> Printed Name: Y (n r 11t�-- <br /> WARNING:FAILURE TO SECURE WORKCRS' COMPENSATION COVERAGE IS UUL <br /> NLAWF , AAD SHALL L SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIF$AND CIVIL FINEZ UP TO Oh'C HUNDRED THOUSAND DOLLARS <br /> (S100,000d,IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S PEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OFTHE LABOR COD[;,. <br /> THORIZATIO FOR DTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, '�� �� ..y./-t'�-- _(s lgna Lure ofC37 licensod Ruth oriutd repres rnfativa), <br /> hereby aethoriz®(print name)___1rJ t _ tClC-f.1� <br /> to sign this San Joaquin County Wall Prrmit Application on my behoif, I Vhdors(snd this authorirotlon is villd for <br /> j one(f)year Ana IC IIm?t1d tc the wort plan Herod on the front pogo ofthla application, i <br /> 8-ZyU2l MI, <br /> 1P12N/' (.W.f 'p• �)Y,:wC (T\'A3 NO .2221 21002 <br />