Laserfiche WebLink
RDM',: West Hazmdt FAX NO. :? 19166388613 Jan. 07 2000 05:53PM 131 <br /> 01/07/2888 12:58 2894671/ AGE ST"TON PAGE 91/61 <br /> 16 <br /> c <br /> Aaaa ss i L,,:�. PaRm sig zr(moby <br /> ,; T,, <br /> LM¢�'.,:.'� 't _ ' :' `k'.'!•.. :':. ,i% �..tt /+}:"` _ `�•:4i �'-'T �•`�arS.u ':=.ypfn•' tr. <br /> r-l. <br /> LICENSED'CONTRACTORS DECLARATION <br /> I hereby affirm that I arts licensed under the provisions of Chapter 9 (Commencing with Section 9000 Of Division <br /> S of the Buscineas and Professions Code)and my license is in fug force and effect. <br /> 1.1Ger"#: Expiratlott Date; U <br /> Doe: r TC0111 .. - �A%dk <br /> - <br /> _w <br /> I <br /> signature: Cc - Tide: kfKn,a <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I her0y affirm under penalty of perjury one of the following declarations., (CHFCK ALL THAT:APPLY) <br /> I have and will maintain a certificate of consent to sell-insure for workers'compensation, as provided for by f <br /> ��Section 3700 of the Labor Code,for the performance of the work for which this permit is issued- # <br /> V 1 have and will maintain workers'compentatlon insu ance,as required by Section 370o of the Labor Code, �I <br /> for the performance of the work fvr which this permit is lssued, My worker's'compenostion insurance <br /> carrier and policy numbers aro: ( `` <br /> Carrier: „ �� Pollcy Number. U <br /> -.., <br /> I certify that in the performance of the work for which this permit is issued. I shall not employ any person in <br /> eny manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workam'compensation provisions of Section 370D of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 7R Zaau -_Sign,atura: r.t� <br /> Printed Name! P-a moi' <br /> WARNING: FAILURE TO SE=CURE WORKERS'COMPENGAT'ION COVERAGE 15 UNLAWFUL,AND SMALL SU13JECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (S IOO;OCIA_y,IN Aat3MON TO YHE Cosi'or COMPENSATION,INTER118T,ATTORNEY'S FFFlk,AND DAMAGES AS <br /> PAIDVIDED FOR IN SECTION 3746 Of THE LABOR CODE, i <br /> IC•67license holder),hereby <br /> authorize +r-r4ar, of J- �G (ronsuWns).to sign this:lion F: <br /> i <br /> Joaquin County Well Permit Applicat en1an my behalf. I undombad this authorization is valid for one(1)year <br /> and 4 limped to the work plan dated on the pont page of this applicotion. <br /> r <br /> i <br />