Laserfiche WebLink
Aug. ly. l�li;," 4: 1yrm advanced ( eotnvi ronmental No. 19U4 P, 1 <br /> San Joaquin County Environmental I'tealth DeparUnent Unit IN Web Permit Application Suppiement <br /> I hereby affirm that I am flemsed under the provisions of Chapter 9(commencing with Section 7WO)of Division <br /> 3 of use Businen and Professions Code and my license is in full farce and effect <br /> License S: [o 57,9 L4 d l Exp'vation date: <br /> Date: 1 Q Caatbactor <br /> Signature: Tltle: <br /> Prfrtfcd nanw 9 W],i C(� <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm txxW penalty of perjury one of ft following dedaratians: CHECK ONE) <br /> _I have and will maintain a cw N c;ae of consent to selfinsum for wwkeis'compensaiian,as provided for <br /> by Section 3700 of to Labor Cade,for the performance of the work Tor which this permit is Issued. <br /> 2Shave and will maintain workers'compensation insurance,a3 mquirod by Section 37DO of the Labor Cade. <br /> for the pwformarce of the work for which this pem*is Issued. My w orkErfS'Compensation insurance <br /> carrier and policy numbers are: Q <br /> Carries Policy NuWmr.. cz-ja f <br /> I certify that in the perfwmance of the work for Wfich this permit is issued,I shag not employ any person in <br /> any manner$o a$to become sub)ect to the workers'compensation laws of California.and agreo aeon ff I <br /> shw1d become subject to the wofkers'compensation provisions of Section 3700 of the tabor Cale.i shall <br /> forthwith comply vdth those provisions. <br /> Expirafion Date• 6W Signaizrnc: <br /> Printed Mame: <br /> WARNING:FAILURE TO 3ECURE VVORKEftS'C=PEN3AT1ON GE Is UNLAWF;dk,AND$HALL se Eur:r.T <br /> AN EMPLOYER TO CRM NAL PENALTIES AND CNIL FINES UP TOONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.).IN ADDITION TO THE COST OF COMPENSATION,INTEREST.ATTORkEY•s FEES,AND DAMAGES AS <br /> PROVIDED FOR W SECTION 3766 OF THE LABOR CODE. <br /> AUTI.OP ATION FOR OTHER THAN C-57 5IGNING PERMIT APPLICATION <br /> k I WLahm WC411ticsnsod autliattwd repnmen ativel, <br /> hereby autlrariM(Print nWMI a� Ika1L e� flellrari � au:rnnw�lw•�w G . <br /> to s{gn this San Joaquin County Well Permit AppftaUwf on my behalf. I understand this autharaatlan is vabd for <br /> one(1)yew and Is 11mk*d 10 tete wont pian daW on the front page of Oris application. <br /> 11-29421 IUI <br /> Sari 29Oz-onr <br /> srtva <br />