Laserfiche WebLink
FROM : West Hazmat <br />0 5 /10/2E100 09:37 2094671118 <br />FAX NO. : 19166388613 <br />AGE STOcKToN <br />May. 10 2000 03:09PM P2 <br />PAGE 02 <br />7467,o/..1 <br />JO ADDRESS: / V Y 7'1; reo-o-fral-' ptirvirt:::: p CA <br />ik <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 3 of the Business and Professions Code) and my license is in full force and effect. <br />License #: 5 52:-/3_22_,_ <br />Date: o Contractor: (A)EST pc7_ T DR I'LL;(1D <br />Signatur C Title: <br />Printed name< fr c-LLILL7t *C:) 06/2.4*Z. <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />have and will maintain a certificate 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 />X I <br /> 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 carrier and policy numbers are: <br />Carrier: //,z•-• <br />certify that in the performance of the work forwhich this permit is issued, I shall not employ any 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' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions, <br />Date: -c:4) SiOnature: <br /> <br />Printed Name: ' 01'47 <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 />(3100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />/ cri-4-22-rj /4,424-3-c/2.41/) I, <br />(C-67 license holder), hereby <br />expiration Date: Of- - <br />Policy Number: 78 244 -2 -? 5 3 <br />authorize 6, 17-4-1r of h viWc Gf (consulting), to sign this San <br />Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one (1) year <br />and is limited to the work plan dated on the front page of this application.