Laserfiche WebLink
05/10/2005 1-10:34 5306628052 WDC EXPLORATION PAGE 02 <br />06/10/2005 08:54 FAX 209 9450021 FJ002 <br />Com. �Pra Com" Y,7- <br />San Joaquin County trivironmental HPalth Department <br />Unit IV Well Formit Application Supplement <br />JOB ADDRESS:/�/YP`� ��` PERMIT SR#: Qd Zz33 <br />LICENSED CON RACTORS DtCLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Divlsion <br />3 of the Business and Professions Code and my license is In full force and effect. <br />Licenge � S� 3 3 2 f �y Expiration Date: d 16Z3v ! 2 04 <br />Date: S l o ' 2�� Contractor <br />Signature Title:'0_1a WLQq <br />Printed name: _i,—e <br />WORKERS' COMPENSATION IDECLARATION <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' compensetion,:as provided for <br />by Soction 3700 of the Labor rode, for the performance of tho work for whlch this permit is issued. <br />�I have and will maintain wwrkers' 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: AIt rs"'dS, Policy Number: yq Ooo 0 I L( q S- <br />I certify that In_4the pertarmance of the work fur which this permit is issued, I shall not employ any person In <br />any manner so as to become subject to the workers' compense6on laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the Ldbor Code, I shall <br />forthwith comply with those provisions, G�A <br />Expiration Data; ( •2�` Signature: <br />Printed Nara®: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 UNLAWFUL, AND' BALL SUBJECT <br />AN EMPLOYEE; TO CRIMINAL PENALTIES AND CIVIL FINES UP TO QNE HUNDREt) THOUSAND dOLLARS <br />(�tao,tloa,), IN ADDITION 70 THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A5 <br />PPOVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTHORIZATION FOR OT LR T! -IAN C-57 SIGNING PERMIT APPLICATION <br />• (signature ofC-57 Iicensecl authorized representative), <br />hartUy authorize (print hA me) V <br />to sign this San Joaquin County Well Pnrrnit Applioation an my behalf. I understand this authoritation Is valid for <br />one (1) year and is limited to the work plan dated on the front page of this applleation. <br />I MI <br />ERD 29-02-001 <br />61=04 <br />05/10/2005 TUE 10:32 [TX/RX NO 56111 U 002 <br />