Laserfiche WebLink
! r I ev :.. <br />JA ; , <br />IV /LOP <br />VA 11 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ;=1,DDRESS: &Jq d 5+(�_-� PERMIT SR#: DD t0 6 ?2_ - <br />LICENSED CONTRACTORS DECLARATION ,,CD) <br />CD) <br />I hereby affirm tnat I am licensed under the provisions of Chapter 9 (-ommencing with Section 7000) of Division <br />3 of the Business and Professions Code nd my license is ;. full fora:. and effect. <br />ic.ense #: GS7 Expiratic_ , Date:_` <br />Date: <br />Signature: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />have and will maintain a certificate of consen, to self -insure for workers' compensation, provided for <br />/by Section 3700 of the Labor Code. for the per; ormance of the work for which this permit is issued. <br />I i ✓e and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />fc, -)e p :rforrr-ince of the wor' or ,,,;iich this permit is issued. My workers' compensation insurance <br />c : � ier and policy numbers ar.- <br />Carrier: S1eaArc/_' 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' 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 />Expiratio: Date:19_Dqr� Signature: _ <br />Printed Name: <br />pno <br />WARNING: FAILURit 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 />AT <br />ZYZPyTIJDN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I(signature ofC-57 licensed authorized representative), <br />hereby authorize (print name)�'j [ wgL <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! M1 <br />EHD 29-02-001 <br />6/22/04 <br />0 <br />