Laserfiche WebLink
Jan-14-00 02:08pm From-ORION ENVIRON44TAL INC, +5628802759 1-160 P Wall F-444 <br /> .SOB ADDRESS: PERMIT SRR: <br /> LICENSED CONTRACTORS DECLARATION (LCA} <br /> I hereby affirm that I ant licensed under the provisions of Chapter 9(Commencing with Section TODD of Uivlsjun <br /> 3 of the Business and Professions Code)and my license is in full farce and erfsct. <br /> Lic ense#: 512268 Expiration Date- 041/3Q,/ZL001 <br /> Date: _ Contractor: <br /> Signature: Tige; W_.�— <br /> i <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 providird 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'compensation insurance, as required by Section 3700 of the t.atwr Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> calmer and policy nurntfers are,- <br /> Carrier: <br /> re:Carrier:�4_9&so.-ri QK Policy Number. NN779 8– <br /> _y,_I certify that in the performance of the work ror which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the arkers'compensation laws of Califvrn€a, and agree that if I <br /> should bomme subject to the wo"rV pen tion provisions of Section 3700 of the Labor Code, i shall <br /> forthwith comply with those provisions. <br /> Date: ��'/* Signature <br /> Printed Name: 1 der <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION C ERAGE IS UNLAWFUL,AND SHALL sUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 1$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. f <br /> 1. 4:4m 19110inflatelfbir OF Rppc> rain HyRtgration. , ing, (C-57licensc holder),flcreby <br /> authorise of (consulling),to sign this Sart <br /> Joaquin County Well Permit Application on my behalf. I un4or*ftnd this authorization is valid(or one 11)year <br /> and is limited to the work plan dated an the front page of this application. <br />