Laserfiche WebLink
Dec 30 OS 12:01p Mit-'-el l Drill -6 2 <br /> iic 707-' '4-9049 P. 1 poo <br /> Dec. 30. 2005 9:59AM 4116C ed GeoEnviroomen t'al �` No. 3391 P. 2 <br /> Sat Jopuln County Environmental health alanent Unit N WNI ps nit �t <br /> JOB ADDRESS: Uft 06byd PERM <br /> i` ,14,0 <br /> A <br /> Nd�pA Hrtt rY <br /> LICENSED CONTRACTORS DECLARATION (LM �fzr'vr <br /> I hereby afkm that 1 am kaneed under the pnavbions of Chaptsr 9(oorrrnrScirrp with Section 7000)of DM Mon <br /> 3 of the Business and Prof tions Code and ny Ncense is in W1 b m end <br /> t_ioense i ion Dow- (.9 3 b jo <br /> Gate: .3o as CorMlaatoi f tAG / L�)l ' <br /> TAW: fsejlJlan - <br /> frfNtbd n.nre• <br /> Gda d <br /> WOR MM,COWMN".noN DECLARATION <br /> I hereby sWm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I haw and Will m*nIain a certillcels of consent to n$*W"for wWorlters'compensation,as prodded for <br /> by Section 3700 of the Labor Code,for tba perfomrence ofthe work for which th is pemntt is issued. <br /> 1 haw and WIN nalirMaln wolkess'WrOOnSIOWn kwunInce,as required by Seclon 3700 of ON Labor Code, <br /> for the perforntartoe Of iM WO(k forwhieh this permit is issued. My workrrs'compensation insurance <br /> carrier and poky numbers are: <br /> r e <br /> Carrier: 1 t!T 1 t!'.SIAM Co. poky,Numbeir: 60s-o 660 f AS <br /> 1 ce>*that In the IWft"W"of"work for W"this Permit is issued. I aftall not employ any person In <br /> any manner so as to beat,nts subIW to the warier M compsnestion satyrs of CaVomia,and agree that it I <br /> shorvid become subject to the wov*sre corttpenvation pmrnlsions of Section 3700 of the tabor Code,l shall <br /> forthwith CWW wNh those provisions. <br /> apkatlon Date' SlOMatare: <br /> Prlmisd Mom: <br /> 1 <br /> WAIWIM ;FAILURE TO SECURE 1NORICERS'COW11INSATION COVERAGE 4 UNLAIPUL,AND$HALL SUBJECT <br /> AN MILDYER TO C MAMNAL PENALTIES AND CML FINES UP TO ONE HUIWQ TIIOUMM DOLLARS <br /> (9100,0OLL IN ADOMON TO THE COST OF 001APEMSATA0I1,WTEREST,ATTORNttiY'S FWS,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 5700 OF TME LABOR COOS. <br /> AUTHORIZATION <br /> �FOR <br /> TQ,j��THAN C-57 SIGNING PERMIT APPLICATION <br /> I, EQ IIIJII' !'t-1'i(./�.iZ�� R 4; AtKu�sipnatnn ofC T ileo aT;VT <br /> d mprsepntatiw� <br /> hereby■uniomm 6"t nsere) Act V <br /> Io elpn%Is son Joaquin Counpr Well Pad Application on my behalf. I undsmiand this authorization Is vend for <br /> Ora(1)yearand le 0edted to tics Work plan dated on the front pap of this application. <br /> 0.21142 IN <br /> sloDZ9oz00� - <br /> 622ro4 <br />