Laserfiche WebLink
SEP 30 2002 4:02PM HP LASERJET 3200 <br />Se 30 02.02:40P Horizon Env. Inc 916 939 2172 <br />San Joaquin County environmental Health Departm nt Unit IV Weil Permit Application Supplement <br />JOB ADDRESS:3INO r--a-yt LLASit + PERMIT SR*:&�3P <br />5 'b -C4 tr►.— <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />p.3 <br />I hereby affirm that I am licensed under the provisions of Chap►er 9 (commencing with Section 7000) er Division <br />3 of the DuSiness annd1P_rbfessions Code and my license is in full force and effect. bb <br />'License 9: _ (.,p�q ExpirationDate ; �Z, <br />DateContractor' <br />Signature: <br />Printed name: <br />e: <br />(dem L - <br />RS' COMPENSATION DECLARATION <br />I hereby affirm uiluer penalty of penury one of the following deciarations (CHECK ONE) <br />_ I have and will maintain a certificate of consent to self -insure for workers' ccmpensation, a3 provided fvr <br />by Section 3700 of the Lat)or Code, for the performance of the work for which this permit is issued. <br />?L( have and will maintain workers' compensat on insurance as required by Section 3700 of the Labor Code, <br />fer the performance of the wurk for which this permit is is6ued. My workers' compensation insurance <br />carrier and policy numbers are <br />Carriar n1) Policy Number: D <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 mannar so or; to b000rre subject to the workers' Compensation laws of California, and agree that if I <br />should become subject to the workers' compea n provis ons of Section 37Q of the Labor Code, I shall <br />forthwith comp�y with those provisions, �j A <br />OCA <br />i <br />Date: C) - Signature: <br />Printed Name: <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWr:UL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIV1 FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />(511Q0.000.1, IN ADEWNDN 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 nam <br />Nignaturre�ofC-57 licensod authorized representative), <br />(n C n ) k-vt -r rqn �s/1 ✓ <br />to sign this San Joaquin County Woll Permit Application url ,ny behalf. 1 understand this authorization is valid for <br />one 11) yoar and is limited to the work plan datod on the front page of this application. <br />a-29-02 / MI <br />p.2 <br />