Laserfiche WebLink
09/18/2003 11:57 WRTER DEVELOPMENT 4 19169397570 NO.162 P02 <br /> SEP-18-2003 THU 10:46 AM A* MICKELSON. ENV' y ', FAX NO, 9160570 P, 02 <br /> San Joaquin County EnVlrpnmentdl Health Services,Unit LY well Permit Application supplement <br /> JOS ADDRESS:-)5' W, ✓AL (GD &I TAA; 1, t.A PERMIT SR#: � $ <br /> LICENSED CONTRACTORS DECLARATION <br /> I 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.d <br /> License#: 2d _Expiration Date: J <br /> .^ J <br /> IF <br /> Dale: q Contractor; ��e 612/0, <br /> Signature; �'� Title: ylC2 �/r°t�Q � <br /> Printed name: Gl e °v <br /> WORgERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> —1 have and will maintain a certificate of consent(o self-insure(or workers'compensation,as provided for by <br /> Section 3700 of the tabor 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 /> for the performance of the work for which this permit Is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> SCI �FEu�t ry rti5 t eA,iC-E ( ) C 5 r D 7- yon! <br /> Carrier:_ cy_ PAn Policy Number; <br /> _I certify,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 the workers'compensation laws of California,and agree that 111 <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:WARNING: FAILURE TO SECURE O - <br /> ENSATIGN <br /> AN EMPLOYER TO CRIMINAL PFNA7LES AND CIVIL FINES up TO COVERAGE SUBJECT <br /> ONE HUNDRED THOUSAND DOLLARS <br /> ($1000,000.),IN ADDITION TO 7�7THE <br /> OF THE COMPENSATION, <br /> MP DAT <br /> ION,INTEREST, Ai-tORNErS FEES,AND DAMAGES AS <br /> PIR <br /> t /f' ,;signature ofCs7 licensed authorized representative), <br /> hereby authorize Iprintname) IL(, P44 r7- V <br /> to sign this San Joaquin County Well Permit Application an my behalf. 1 understand th(s authorization is valid for <br /> one(1)year and is limited to the work plan dated On the front page of this appiicntion. <br /> s_11-24001M1 ----"-- ...... W_.._.. ......_ <br />