Laserfiche WebLink
V e cck_ <br />JOB ADDRESS: <br />San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br />PERMIT SR#: <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 />License #: 51 —7 I 7 5 0 Expiration Date: <br />Date: 5--- -0 I Contractor: CGLSC Dr- ( ;e q r\C <br />Signature: Title: C 10( r Cc fl y•-‘ S (VA y\c4 v-c <br />Printed name: name: Yftrci_ C-k ck_f) (, tc-\ <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 />.11. I 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 fcSkANict..4-10i\4) Tr\S. Policy Number: (-) vv 3 -s - I <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 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: 5----) --0 <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 SECTION 3706 OF THE LABOR CODE. <br />1, VC tra_ C p <br />authorize Dc7 \J c A c r z__o <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 />I - ( <br />Signature: <br />(C-57 licensed authorized representative), hereby