Laserfiche WebLink
0Qc-22-99 03:18P Kvilhaug Drilling 925 685 6678 P07 <br />.• <br /> <br />San Joaquin County Environmental Health Service., Unit IV Well Permit ApplicatiPn Supplement <br />JOEVADDRESia:15 r4D. VALP 1 co RD) TP,AcY PERMIT SR#: <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affIrrn that I am licensed under r'e provisions of Chaote - 9 (commencing wit) Section 7000) of Division <br />.3 of t'ne Business and P:cfessions Code and my license is in full force and effect <br />License ft: L'-• \-.K q n Expiration Dote: // — 3'7 -_J2 001_ <br />Dale /.2 - (9/ - _7'7' 7 Contractor WO 4 /1,-41., (., ._,./k-_///i.Aj C, .----- <br />Signature: _I-91" Title: <br />Printed name: /11--A) 11 14 I-1 /1 <br />WORKERS' COMPENSATION DECLARATION <br />i hereby af5rrn under oenalty of per)ury one of the following declarations (CHECK ALL THAT APPLY) <br />I have and vvill mainta n a certificate of consent to self-insure for workers compensation, as provided or by <br />SOCItOn 3700 CI the Labor Code, for the performance of the work for which this permit is issued. <br />ij I hove and will maintain workers' compermatIOn InGurance, & elOad by Section 3700 of the Labor Coda <br />for Me performanCe 0' the WO* f0^ which this permit is issued. My workers' compensation insurance <br />carrier aria poliCy nurnbens arei <br />rr49r• rs' 1Th <br />I cert 4y that in the performance of the work for which this permit Is issued, I shall no: emplOy any person In <br />any manner SO as to become subject to the workers' compensation laws of California. and agree that i‘ I <br />should became subject to the workers' compeneatio7 provisions of Section 3700 Of the Labor Cade, snail <br />forthwith corny with those provierOn3. <br />Date: 4-2 - / Signature: <br />Printed Name: <br />*ARNING FAILuRE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINE8 UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000). IN ADDITION TO THE COST OF CcupEN9ATioN, INTEREST, ATTORNEY'S FEES, AND DAMAGES e.5 <br />PROVIDED FOR IN SECTION 370e OP THE LABOR CODE. <br />IC-57 licensed authorized representative), noraby <br />authorize <br />to sigr this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br />one (1) yaw and Is !hilted to the work plan dated on the front page of this applieavon <br />mew <br />1,4:JIAD'E 666L-7Z-7.[ <br />Policy Number: c2, lc ‘. \ Q.