Laserfiche WebLink
JA1/1101510 <br />10/27/2000 09:34 714G926754 EAI PAGE 03 <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />PERMIT SR#: ta7/1/cr JOB ADDRESS: San Joaquin Delta .College <br />5151 Pacific Avenue <br />Stockton, California <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter (commencing with Section 7000) of !Division <br />3 of the Business and Professions Code and my license is in MI force and effect <br />License 4: <br />Date: <br />Signature: <br />Printed name: <br />Expiration Date: __Itp f'3 I <br />actor: c.. . <br />NaL -0; 1,11.. AL TltI :e -Q.. I? riac. ; <br />r <br />Cn 9-11-7 <br />(-kr s <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I 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 />I have end 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: E—a_ta L. <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 manner so as to become subject to the workers' compensation laws of California, and agree that if <br />Should become subject to the workers compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions <br />Date: 10.3p 20 Signature: <br /> <br />Printed Name: Cik ("- <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 />R100.0004, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (C-57 licensed authorized repreeentadve), hereby <br />I PlAr r <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 />5-17-2000 I MI <br /> <br />Policy Number; <br /> <br />4-5 boot) <br /> <br />authorize <br />abed <br /> <br />!00:01. 00 -0E -130 !0E0 EE 96 'oui 'OuT;sei OuTITTJO MaJo :A9 1J_Ja7,