Laserfiche WebLink
4 <br />San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br />JOB ADDRESS: /.'OZ A). E/ 126,,,A PERMIT SR#: Dg3�66 <br />S'10.1ek- , C*. <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 #: � � 1 `1 �� � Expiration Date: � �,1%S� U 1 10,08 <br />Date: I I " �I Contractor:Ye-�7, <br />Signature: Title: L 0/)c- M6 in Q <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 />carrier and policy numbers are: I , ' ( <br />.Carrier: Mosgg l Policy Number: W C O Z ( 7 <br />_ Os , <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 Iaw�Qf California, and agree that if I <br />should become subject to the workers' compen s— ions of Sec 700 of the La r Code, I shall <br />forthwith comply with those provisions. �att/io>roPj / <br />F <br />Expiration Date: 1 O7Sign ure: <br />Printed Nam _ - <br />WARNING: FAILURE TO SECURE WORKERS' COM NSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND IL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO THE COST OF�A.OR <br />PENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE CODE. <br />AUTHORIZATION F013.bTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, 01 � � (signature ofC-57 licensed authorized representative), <br />C/�� <br />hereby authorize (print name) �N <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 l MI <br />EHD 29-02-001 <br />6/22/04 <br />