Laserfiche WebLink
08%26/03 TUE 11:48 FAX 510 6 4141 GEOMATRIY OAKLAND • U014 <br /> 3� <br /> Ban Joaquin County environmental Health Department Unit IV Well Permit Application���m,ent <br /> JQB ADDRESS:9aQ Ze,-rpt�j r �,tit PERMIT SR#:_„ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of DiviSion <br /> 3 of the E lusiness and Professions Code and my lirange is In full force and affect, <br /> License#:GS7 e0ration Date: <br /> • r <br /> Date: CoMraetor: <br /> Signature: t <br /> , <br /> Printed risme: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one Df the following declarations: (CHECK ONES <br /> 1 have and will maintain a certificate of consent to self•ineure for worke+r$,compensetion,as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <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 id issued. My workers'compensation Insurance <br /> carrier and policy,numbers are: <br /> Carrier: Policy Number, ee mo m <br /> I certify,net In the performance of the work for which this permit Is Issued,I shall not employ any person In <br /> any manner to as to become subject to the worker&'compensatlon laws of Celifomle, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Coda, 10811 <br /> forthwith comply <br /> /with those;provisions. <br /> Date:�� ' ,Signature- <br /> PClnted 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"UNDRED THOUSAND DOLLARS <br /> ( N ADDITION <br /> 7 6 OF THE LABOR CODE <br /> O T14E COST OF ION,INTEREST,ATTOFtNEY'S FIRMS,AND DAMAGES AS <br /> PRbVLREO OR <br /> AUTHORIZATION FOR OT THAN C-37 SIGNING PERMIT APPLICATION <br /> I gnatuw ofC-57 licenced authorized roprosanlativei, <br /> hereby authorize(print name)-- P a� Ma ��^ <br /> to sign this Son Joaquin County Well Permit ApplicaUon on my boh5lf. 1 understand this authorisation Is valid far <br /> one(1)yw and IS Ilmltsd to the work plan dotad on the front page of NO appilaaticn. <br /> e-28.02 I Ml <br /> Z00I� INVIAYO x1x1 'W030 rirTt C98 OTS %Vol ZZ:00 311,E CO/89/90 <br /> Z 'd QDaE 19rti3su-i dFi Wti1o`17 :6 EOOZ 9z onu <br />