FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement JOB.ADDRESS: PERMIT SR#: �aZS�3 LICENSED. CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business and Professions Code my license is in full force and effect. License#: Expiration Date: Date: Con r: Signature: I Title: Printed name: XORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) I have and will maintain a certificate of cons. f-insure for workers'compensation, as provided for by Section 3700 of the Labor Code, for th rformance of the work#or which this permit is issued. I have and will maintain worke compensation insurance, as required by Section 3700 of the Labor Code, . ___for the performance of the rk for which th' permit s issued. My workers'compensation insurance carrier and policy num s are: - Carrier: Iicy Number: _ I certify that in the perfo ante ofyte hich this permit is issued, I shall not employ any person in any manner so as to become subjers'compensation lawsof California, and agree that if I should become subject to the woration provisions of Section 3700 of the Labor Cade, I shall forthwith comply with those provis Date: Signature: Printed Name: WARNING: FAILURE TO SEC)3706THE KERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000.),IN ADDITION TO OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS. PROVIDED FOR IN SECTION LABOR CODE. 1, (C-57 licensed authorized representative), hereby authorize Geo�.E Com,X1 -5 to-sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(1)year and Is limited to the work plan dated on the front page of this application. 5-17-20001 MI