Laserfiche WebLink
bZ/17//2bl7b 117:14 y1bb38b 1 CASCADEDRILLING PAGE 02/02 <br /> .� 02/03/2006 16:31 916861 SECOP. ��- <br /> J <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appli//c24ionSu plement <br /> JOB ADDRESS: �G C We kk t/ PERMIT SR#; b� �_ C <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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. <br /> License5( 0 Expiration Data: 1 -.11 - 0c <br /> Date; - D Cr Conte <br /> Signature: <br /> Printed name: &YyIIVA �, (4���✓r^S 2�_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> I have and will maintain n certificate of consent to self•idsure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code.for the performance of the work for which this permit is Issued, <br /> 1 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 /> carder and policy numbers are: <br /> Carrier, Civil d 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'compansatlon laws of California,and agree that if I <br /> should become subject to the workers'eompensatien provisions of Section 700 of the Labor Code, I shall <br /> forthwith comply with those provisions, <br /> Expiration Date- 1 d Signature: t� � <br /> Printed Name!cfaj,9 j __C-- ; <br /> WARNING:FAILURE TO SECURE WORKERS,COMPENSATION COVERAGE 16 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370E OF THE LABOR CODE. <br /> ALITHORIZATIO FOR HER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signetene ofC-57 Oeenoed authorized mpresentativo), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well POMIlt Appllration on my behalf. I understand this authorlxttlon Is valid for <br /> one(1)year and Lc Ilmited to the work plan dated on the front papa oft is application. <br /> 8.29.0'1 r MI <br /> GHD 29-07.001 <br /> 6171104 <br />