Laserfiche WebLink
San Joaquin County Environmental Health Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS : , I O5 n GCID 5t • PERMIT SR#: <br /> 6 tXicn <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <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 /> License 7 <br /> ��#: It: Noq Expiration Date : <br /> Date : "y ' I -oo Colxeknt40 <br /> tour: `� � 0 I (1LI lf)L <br /> Signature : Title: <br /> Printed name : }tf L <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 provided for by <br /> / Section 3700 of the Labor Code, for the performance of the work for which this permit is issued . <br /> V/ 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 /> an <br /> Carrier: i� aI t 117, fyj Policy Number: 9 ) , 0j� 3 � <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 become subject to the workers' compensation provisions of Section 700 of the Labor Code , I shall <br /> forth�wji comply with those provisions .Date : I 00 Signature : ac., <br /> Printed Name : _ ��11_^.,. 4 ff v I ( �}�yL <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 <br /> ($100,000,)5 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 /> (C-57 licensed authorized representative) , hereby <br /> authorize <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one (1 ) year and is limited to the work plan dated on the front page of this application . <br /> 5.17-2000 / MI __ __ <br />