Laserfiche WebLink
12/09/2003 TUE 13:21 FAX 2002 <br /> L N%001 <br /> 447 <br /> r� <br /> tjnit'IV Well Pennik-Application Supplement <br /> San.Soaquin Cflunty Environmen. 1 Wealtkt 5ery e A, - <br /> JOB ADDRESS: <br /> PE�RNl1TS[�#` <br /> LICENSED CONTRACTORS DECLARATION WL Q) <br /> 1 hereby athrm thet I alTI licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Gusiness grid professions Code and my license is in full force and effect_ <br /> fisl/1 D.4/ Expiration Date; <br /> License#: <br /> aDate: r.0 ontracto <br /> Title: <br /> signature: <br /> Printed name' J <br /> WORKERS' COIWpENSATION MCLARATION <br /> I hereby affirm under penally of penury one of the following declarations: <br /> 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 /> I have and will maintain workers'Cotrtpensation 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 /> ���� Policy Numbe <br /> r <br /> • <br /> Carrier: - person In <br /> _I certify that in the Debecome <br /> Come ucq bjtect t theile work fwo keor rs compensation this permit�o^laws of Calarfornit wand agree that if 1 <br /> any manner so as to <br /> should be-Come sub eCt to the workers,Compensation provisions of Section 3700 of the Labor Code.I aha <br /> forthwith ornp with those proVls ! <br /> Date* <br /> Signature: 40L x <br /> _ <br /> Printed Name: '�9—i Ji . YL <br /> I I ON COVERAGE IS UNLAWFUL,AND SHALL SUBJFCT <br /> WARNING'FAILURE TO SECURE WOR ES ANDCIVIL F NES VP TO OMPENSAT N HU BRED HQUSANDADOLLARS <br /> GES AS <br /> AN I:Wlpt-OYER TO CRIMINAL Pel�lat <br /> ($gDo,DDa•},IN RDIN SECTION 370 of T EFLABOR cotaEloN, INTEREST,ATTORNEY' <br /> s FEES, <br /> PROVIDED PO <br /> 1C.57 licensed authorized represcntativ ), h e y <br /> authorIZ0 <br /> to sign this San-toaquin County Well Permit plication on my behalf. 1 understand this 2,utt�vtization is slid fOr <br /> one(1)Year and Is Ilmltad to the <br /> work plan dated on the front age <br /> of this ap tication. <br />