Laserfiche WebLink
I <br /> C/v <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Suppppplement <br /> JOB ADDRESS: 189Co,r•,�,r +C1V13 a1V�. PERMIT SR#: K/ / f <br /> i <br /> 5TccIf.Toe, <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <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 /> AQ <br /> License#: y `�� Expiration Date: <br /> Date: `p !� of Contr r: _CIV `1'"1 7N <br /> Signature: �j Title: 6r:>Y�s ftkLIJ/)C <br /> Printed name: `1 S � 1 fu vI6K <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> 1 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 this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: iyn4it Policy Number. `Z 1 <br /> I certify that in the performance 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 I <br /> should became subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. f <br /> i <br /> Expiration Date: k Signature: L- <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 k <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 /> AUTH 1 XrION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, -�; / (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) If�1 GV£4.4/- <br /> a j <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> ` I <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29-021 MI <br /> EHU 29-02-001 <br /> 6/22/04 <br />