Laserfiche WebLink
Sep, 10. 2001 12: 11PM AP, GROUP SERVICES INC. No. I J I V r. <br /> San Joaquin County Environmental Health Department Unft IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SRN: 00 5 I `39 <br /> LICENSED CONTRACTORS DECLARATION LGD <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#: ?"c) ExpireMonnDate_1a 3 I <br /> Date: J Contra ST: 0 r-' LL I <br /> Signature: r Title: <br /> Printed came: 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: r <br /> Carrler: Pollcy Number' 713 -15-5-3-7 "�Y <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 provisi Section 3700 of the Labor Code,I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: ASignature: <br /> Printed Name: LL&-L-- <br /> WARNING.FAILURE TO SECURE WORKM'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (it00,0o0.),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 /> AIH ON FO ER THAN C-57 SIGNING PERMIT APPLICATION <br /> I <br /> I, (signature ofCd,7 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Penult Application on my behalf. I understand this authorization is valid for <br /> one(1)year and Is United to the work plan dated on the front page of this appleadon. <br /> 1 <br /> 8-28-021 MI <br /> i <br /> FAD 29-U24kl ' <br /> CJ72/04 <br />