Laserfiche WebLink
San Joaquin county Environmen.at Health Services, Unit IV Well Permit Application Suppiamen. <br /> J02 ADDRESS: P,=rZMi E SRS: <br /> LICENSED CONi7RACTORE DECLARATION <br /> I harahy affirm the,I am licensed under the provisions of Chapter 6 (mmmancing with Section 700m)or Division <br /> 3 or the Business and Professions Code and my license is in full force and effect. // <br /> Cleanse r: 63 I Expiration Date: 1 �2 1 /Zrjv u <br /> Date al /� 6 ConMactor; ✓ d n r ✓� , <br /> Signature. Title: _ e t`^, _ c�a a V2- <br /> Printed name 3 ¢ e <br /> WOP.KEPS' COMPENSATION DECLARA310N <br /> I hereby amrm undar penally of perjury one or the following dscieratiorzst (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate o`consent tc self-insure for workers' compensation, as provioed for by <br /> Section 370C a:the Labor Code, forthe performance of the work fa which this pennV s issued. <br /> ] I have and will matnfain workers'compensation insurance,as required by Section 3700 of the Labor code, . <br /> for the performance of the work far which this permit is issued. My werkars'comoansation insurance <br /> --artier and Doiicy numbs,&are: <br /> Carrier `' ' � / �rv`-f.;<� Policy Number. C-'-!C1 9-7 -,Z- c1!C <br /> I carafy that in the performance of the work forwhieh this permit is issued, ' snail not empitt any parser in <br /> any manner s0 as to become subject t0 the workers'compensatior taws of Callfornia, and agree that v <br /> should oecome s.ibieat t0 the workers'compensation provisions o;Section 3700 of the Labor Code, 1 shall <br /> forthwith comply with those provisions. <br /> Data: Signature: <br /> Printed Mame: <br /> WARNING:FAILURE i 0 SECURE WOR,IC=Rs'comP=NsxnoN Cov=-pAGE Is uNLAWrUL,AND SHALL suii,l_=CT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINS UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S10C,00C.'„ IN ADDITION TO THE COST OF COMPENSATION,INTEREST, A—ZrORNSY'S FEES,AND DAMAG S AS <br /> PROVIDED <br /> POP.IN SECTION 37 DE OF THE AOR CODE. <br /> {Co'7 licnnsed authormad rooresantative), hereby <br /> author a ✓. ✓J-.. -1 Lr . �r� /CI <br /> to sign this San Joaquin County Wel, Permit Application on my behalf. I understand this authorization Is valid for <br /> Eno{1)year and is limited to the work Plan dated on the trot -"' ----5-'7-200 r MI <br />