Laserfiche WebLink
JARIAUg't104 04 04:48p <br />02/04/2004 16:06 <br />HORIZON <br />916-852-9558 <br />p-2 <br />PAGE 02 <br />San Joaquin Countynj i�� ental Health Dep Unit N Well Permit Application Splem0 nt <br />JOB ADDRESS: t I1`''- PERMIT SR#: 4 72 <br />(t4W -Cj) 446. (AfcA M(+ - 0 3o — v `/ <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 />license #; 6 ! Z 17 Expiration Date: <br />Date: �I �I vim! Contractor: <br />Signature. Title: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penafty 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 />41 have and will maintain worker;' 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 />Carrier. V �%� SvjO5T Policy Number. U✓ S — UZ� �S�`�6 <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 become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: <br />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 />($100,000,), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />hereby authorize (print <br />t,, -/ S,- f r I <br />nature ofC-57 licensed authorized representative), <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this application. <br />8-29-02 / MI <br />