Laserfiche WebLink
03/UJ/:eIJTJb U9 b3 ZU1J4bbJ4JJ !F 1H h LUUK HUC G 4 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: t 4 0 t E, Ila S E M I T E Ayf , Mh MTECA PERMIT SR#: Lf <br /> W 0 -7 <br /> LICENSED CONTRACTORS DECLARATIONLSD <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 /> License# G-,57*� 677-9 )7 Expiration Date <br /> Date _z� r d_ _ Contractor 1A I T-6 t21 LL(N N 1/- Ga I_ <br /> Signature, Title V' tr <br /> Printed name- <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 a certificate of consent to self-insure 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 /> 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 /> earner and policy numbers are <br /> Carrier: U i�7t N 1+� t1 Li .. Policy Number 15, 00016586 <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 if I <br /> should beoorne subject to the workers'compsnsation provisions of Section 3700 of the Labor Cade, I shall <br /> forthwith comply with those provisions <br /> Expirabon Date ��_- Signature ----—-----------------_-----------------_----.--- <br /> Printed Name .___--- -------�_-- -------- -------------------_- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS <br /> (PROVIDED FOR ECTION 3706OF T OF <br /> FLABOR CODE. N,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> AUTHORIZATION FOR ©TREK THAN C-57 SIGNING PERMIT APPLICATION <br /> I (SignatLireofC-57licensed authorized representative), <br /> hereby authorize(print name) TG S E P A M R <br /> to sign this San Joaquin County Weu Permit Application on my behalf I understand this authortxation is valid for <br /> one(1)year and is limited to the worts plan dated on the front page of this application <br /> 8-29-02!Ml <br /> EWD 29-02 001 <br /> 622/04 <br />