Laserfiche WebLink
FEB-05-2001 13;22 FROM PRECISION SRMPLING TO 12094603433 P.01 <br /> San Joaquin Coon arty Envir nimentai ea Se <br /> Sft rvfces,unit N Wetl Peomlt Agplioati0ab Supplement <br /> rJOS ADDRESS: d� S• � � PERMIT SR#: I <br /> LICENSED CONTRACTORS DECLARATION Lt Com} <br /> I hereby af.inn that I em licensed ucder the Provisions of Chapter 9(wrnmencAng with Section 7000)of Division <br /> 3 of the 2.usiness and Prefesrons Ccde and my incense is in full force and otfect <br /> license it 3 6 387 Expiration Date: I 31 <br /> Date: <br /> S Contractor. �r s i o Ss r!1 iN C . <br /> signature: <br /> Printed name_.. �fi r y �jQ_R.n <br /> VVORKERS' COMPENSATION DECLARATION <br /> t re eby aiFrrt under penatty of p rjt ry eno of the toliow ne dectarat ons (CHECK ALL THAT APPLY) <br /> I have and will maintain,a ce :ficate of consent to self insure for warkets'cumpetsation,as provided for by <br /> Sectmn 3700 of Cie labor Code,for the perforn.2nce of the wort:for which tha permit is issued. <br /> l I have and will maintain workers'compensatcn insurance,as required by Section 3700 of the Labor Code, <br /> 10 the Feliofmance of the work for which this permit is issued. my worters'Compensation insurance <br /> carrier and/polo?r n•-.M. bers a/fie L <br /> (�.r�! iyLT1_ .4 _Policy Number; WCt "�'Z.�'�?2-33p- O/o <br /> Carrier._�_,_._�_.... r <br /> I cer dy that in the perfa-mance of the work for which this permit is issued; I sh311 not emptoy any person in <br /> any manner so as to become subjeot to the workers' compensation taws of Califon a,and agree that.if I <br /> should become subject to the workers'compensation provisions Of Section 3700 of the Labor Code.I shall <br /> fomwo comply with those Fr 13*ns. <br /> I <br /> Dat2;_�/slQ,t? Signature!..�`Ua <br /> Printed Name: <br /> 1 WAzOUNG:FAILURE TO SECURE WORKERS'COMPF.NSATfON COVGRACE IS UNLAWFUL,AND SHALL SU9.SEC7 <br /> AN MPLOYER TO CRINRNAL PENALTiFS ANO CIVIL F:NFS UP To ome HuNPRFD THOUSANn DOLLARS <br /> IN RTo <br /> FOR MON N Hr OOST <br /> TtOFi-ABQR CODE1ON INTERERR <br /> ST,ATTORNerS Fe25.AND DAAGFS A3 <br /> pRC3Y1pEp <br /> (-- 5✓ N n gCb"r eixmegd ati1horized representative},hereby <br /> to sign this San 3oaqu�county Well Pemtit Application on my behalf. I understand ttrs authorization is valid for <br /> Ifearandis iimttetl to the_wank tan dated an the front a or this aoplicatfon. <br /> i <br /> Post-it•Fax Note 7671 ogre 1, J$ Ui v 9es0. 1 d�y� !C <br /> TO �cr grEr 4S .e Fram Cwr �., f :. t' O 200 <br /> Co./Dept , o - AN 3 1 <br /> /'�CrS ie... �j <br /> Phone Phone# .rho ENVP(�E� H��A�`LAR <br /> Fan# Ty_Y y4 � 0) F-4 L u1 4' 1 <br /> PERMI S�p���-;���-�����=� <br /> c.d WdS£ STSST" ai�� puro ug,.;: 1,081 <br /> TOTRL P.01 <br />