Laserfiche WebLink
JUL 29 2003 4: 06PM H`' LASERJET 3?00 P. 1 <br /> San Joaquin County Environ <br /> nnmental Health Services, Unit IV Well Permit Application Supp�leement <br /> JOB ADDRESS: 2%+ ( lY240Z PERMIT SR#: 6D3�T� <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License# Expiration Date: <br /> Date: Contractor: <br /> Signature: Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by <br /> 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 thi permit is issued. My workers'compensation insurance <br /> carrier and policy numbers arq <br /> Carrier: Policy Number: <br /> _i certify that in the perfor nce of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if 1 <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> Printed 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 HUNDRED THOUSAND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I' C (signature oIC-57 licensed authorized representative), <br /> i <br /> hereby authorize(print name) ILIn12e - Id����� <br /> to sign this San Joaquin County Well Permit Application.on my behalf_ I understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 5-17-2000!MI <br />