Laserfiche WebLink
1002 <br />c 6 " <br />San Joaquin County Environrnentrat liealtkt Services, Un1t.IV 1f1'eIl Permit ApplicatoNeWertt <br />2 mG;,_ S-}- PERMIT SFS.#: <br />JOB ADDRESS:_ Oro <br />C -A <br />LICENSED CONTRACTORS DECLARATION (LC-) <br />I hereby affirm that I am licensed tinder the provisions of Chapter 9 (commencing Witt? Section 7000; of Division <br />3 of the Busin <br />e <br />ss and professions Code and my license is In full force and effect. <br />License #: /_ Expiration Date. _TY <br />t7ate: — <br />ontractor: C <br />Title:rJ (0// <br />- — <br />Signature: (,n,, <br />Printed name: J 1 <br />WORKERS' COMPENSATION DECLARATION <br />I heroby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />Sectionarld 37001of the Labor Codl maintain -a fc for the performanceof consent f -insure for workers' of file work for which this perml�is iasuedvided far by <br />V 1 have and Will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, <br />y^ for tie performance of the work for which this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are; _ <br />Policy Number: <br />Carrier: <br />_ I Cerny that in the performance of the work for which this permit is issued, I shalt not employ any person in <br />any manner so as to become subject to the workers' compensation laws of California, and agree that it) <br />should become suojectto ttie workers' compensation provisions of S�tion 3700 of the Labor Code, I sha11 <br />fortnwith comply with those provisions. J - <br />Date: <br />3 0`' Signature: _ �� / _ %[+-J <br />Printed Name: — �_ �r i U, — <br />WARNING: FAILURE TO.SWURZ WORKFRS' coMPFNSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMtt�WL"P t -r•IES ANA CIVIL FINES UP TO ONE HUNDRED THOUSAND-3FEE,A DOLLARS <br />($100,000.}, INA O CRIN TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR iN SECTION 3706 OF TH5 LABOR CODE. <br />/1/11) / [ "i7 1C-57.lipensed authorized representative), hereby <br />al <br />to sign tp"quip County Well Permit APPlica"n on my tsehalf- <br />I understand this authorization i9 valici for <br />one t1 } ear 2rnd !s limited to tfic work plan datod pn the front pa a o` tills application. _ <br />.. nd is <br />WJ:_--i liv G S' u I G -E L; 1 – V©-11 1 <br />