Laserfiche WebLink
San Joaquin County <br />Environmental Health Services, Unit IV Well Permit Application Supplement <br />JOB ADDIRESS: <br />JAN <br />-Z?Z— r�a2fb_&M+ERMIT�2 Z SR#:v <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 />: <br />Expiration Date: O _ _ ' 0 7 <br />License # <br />�.. ,., �. <br />Date: Contractor: l?1'r U!/ ��[ �'s Is+ - ff F toSignature: Title: W,zd <br />I <br />Printed name: <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of pMury one of the folioiMng declarations: (CHECK ALL THAT APPLY) <br />l have and will maintain a ce►tificate 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 />,9I 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&zd_ . r df1' �/' Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I shall not employ arty 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 workers' <br />provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply With those provisions. <br />Date: - �d 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 />$10(),D IN IN MON Ttt HE COST OF OF THE LABOR COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />IDEFOR <br />I, /1 <br />(signature ofC-57 licensed authorized representative) <br />hereby authorize (print name) ktA3 m9Zt_ 7 . <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 />P A� • ru%n , SAI <br />Z/V a6ed `•BV:OV 10-82-6nv `ZOEO EVE SZ6 `'OUI `6uT;Sal 'g 6uTTTTua 560JS :43 ;uaS <br />