Laserfiche WebLink
0/, ?) b <br /> U6'41 411 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application <br /> Supplemental <br /> JOB ADDRESS: /61v70 tw,5� , Ipde /P{ivE _PERMIT SR # D U d <br /> �n r�aai° e",q Psz.3p <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: 283326 Exp Date: 6/30/2010 <br /> Date: 11/19/08 Contractor: WDC Exploration & Wells <br /> � Field Operations Manager <br /> Signature: �'�' ,_.�.n�,G- Title: <br /> Print Name: Kenneth B.Cook <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued, <br /> X I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Attached Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 4/01/09 Signature: x . <br /> Print Name: Kenneth B.Cook <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (7.e- (Signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> e/28/02/MI <br /> VSIOY WELL PERMIT APP <br /> EHD 2D01 1 <br />