Laserfiche WebLink
N r <br /> _.ix_ _ .i. -.- , :_r.�. • � is ^�.� -• :r.ir�•..- .F•' - ' <br /> 'JOB ADDRESS. = - •r. = PERMft SR#:' - <br /> 7�.:n':'" Cy A? =�Z...� ♦ .��.i.�•F-�T".�r�K:' YJ; l••^,t."��:�� :. T .i <br /> •�f.Zi:a,'Y5 R'�.rti! ��at' -..A.•.��- VY_'v_� .�•�'�':.w - lit:- �'..`'. .�Li• <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby sf&m that Ism licensed undo,the proviWons of Chapter 4(wmrn r►cing wlttt Section 7000 of Dmolon <br /> 3 of the Business and ProfessioOne Coda)and my license is in full force and effect <br /> License#: ��-��-f- ! -- Expiration Date: J A,94 3 I Z P o <br /> Dale: /2/ T Contract r. <br /> now$fattatUre: <br /> Print* na <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 certifca1v of consent to self-Insure for workers'compensation, as provided for by <br /> ��Section 3700 of the Labor Coda,for the performance of ihs work for which this permit is issued. <br /> Xt have and will maintain workers'compensation insurance,as required by Section 3700 01 the Labor Gone, <br /> for the performance of the work for whloh this permit Is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier:� 5 /N5 Policy Number. <br /> Z,wtify 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 tho 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 wl n those provisions. <br /> Date: !( f <br /> 2!/v / Slgnature: �• <br /> Printed Name: <br /> WARNING:.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> All EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES U?TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100;000.), IN ADDITION TO THE COST OF COMPENS_ T TEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> pfloi+feeD FOR IN SECTION 3706 OF THE LA;90 E. <br /> (C-67 license holder),hereby <br /> authoriza r 130 1fV� of G� CK6 S Q�co 1 ulting).to sign this San <br /> Joaquin County Well Permit Appllcatlon on my behslf. f understand this authorization is valid for one(1)year <br /> and is limited to the work plan dated an the front page of thin application. <br /> t <br />