Laserfiche WebLink
0di. <br />San Joaquin County Environmental Health ��Services, Unit IV Well Permit Application Supplement <br />JOB ADDRESS: D,3 S. CQ.«,�� PERMIT SR#: 902-131 <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 #: C S7 71 -7 S__/ Q Expiration Date: /' -3 l d �)-- <br />Date: Contractor: C S�'G� DC1l / /�_J9 70 C <br />Signature: Title: <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by <br />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: <br />Carrier: A!r C's-kn- / ��R =�-S 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' compensation7PI <br />of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. f <br />Date: 6� �� f/ 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 />1 Ve r� C A 67r 1J tv? 0 r\ (C-57 licensed authorized representative), hereby <br />authorize noy2 / / Z O cq <br />to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) vear and is limited to the work plan dated on the front page of this <br />