Laserfiche WebLink
68/16/2008 10: 54 5307873371 VANNUCCI ILCHNULUGIS PAGE 02 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <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 lTly license is in full force and effect, C <br /> License#: o r/!y 74 C, _Exp Date: 9 —3n — znn S <br /> Date: Contractor: / I� r <br /> % rFcsLn,elec roc <br /> Signature: JA Tit;3: 1,It=1C <br /> Print Name. <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the follckving 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 /> /J permit is issued. <br /> X/ I have and will maintain workers' compensation;insurance, as required by Section 3700 of the <br /> 7—Labor Code,for the performance of the work fes which this permit is issued. My workers' <br /> compensation insurance carrier and policy nugtbers are: I <br /> 5 0. 0 COmS0.�iM I: <br /> Carrier. nsrl�nnr4 I v,d Policy Number. <br /> ,I <br /> I certify that in the performance of the work for jnhtch 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 /> Exp. Date: Signatul"e: <br /> Print Nano: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVF;fooE Is UNLAWFUL,AND SHAD SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO f100,000,`jW ADDITION TO THE COST OF COMPENSATION,INTEREST, . <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN3ECTION 3706 OF T14E LABOR CODE, <br /> AUTHORt�ATION FOR OTHER THAN 0-57 SIGNING PERMIT APPLICATION <br /> rlLl�a- ([m c (sigt pture of C-57 licensed authorized representative), <br /> hereby authorize (print name) _ p �LcOr,�._ —_..._._ _.....__. to <br /> sign this San Joaquin courtly Well permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the Iront page of this application. <br /> RnvevMI <br /> EMD20-01 11/497 WELLPERMRAFF <br /> I <br /> t <br />