Laserfiche WebLink
Carrier: Icier) E.-061e, Policy Number: WC-54-1456 ,7-05 <br />PERMIT SRO: 2-9 JOB ADDRESS: .216 <br />44.) 5&G' <br />LICENSED ONTRACTORS DECLARATION (LCD) <br />San Joaquin County Environment I -Health Service*, Unit IV WeIVFermit-Applicatico Sup merit op2.52-, <br />0, / <br />I hereby affirm that I am licensed undor 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 />License #: 1.70196"7/ <br /> <br />Expiration Date:2-- <br />Date: ‘Z/g40/0 / . ontractor: Valij I)-7 . I firyi - I n c - <br />Signature: a_ dh,i,..i Title: 101-4C1-02-,--4) <br />...1 ' <br />Vi (hr-rzi <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 />V I have and will maintain workers.' compensation insurance, as required by Section 3700of 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 />I certify that in the performance of the work for which this permit is issued, 1 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 <br />forthwith comply with those provisions. <br />Date: 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 />($100,000.), IN ADDITioN TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS <br />PROVIDED FOR IN smnoN 3706 OF THE LABOR CODE, <br /> (C-57 licensed author" ed repr .er ntative), hereby <br />Zin\j1V7711-0\k ikk <br />to in 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 />Printed name: <br />41.111. 11 4.-.1 <br />authorize v4 yvL <br />/402/20/2001 TUE 14:26 FAX 916 777 4101 V 1 DRILLING INC VI 002 <br />t •'NJ <br />1„.40.1d vniT2S: t 666