Laserfiche WebLink
�.' <br /> 03/02/2004 14:07 209-579-2225 MODESTO ATC PAGE 03 <br /> San ,Joaquin County Environmontai Health Services,Unit IV Welt Parrnit Applica'Ion Supplement <br /> t r �� 37139 <br /> JOB ADDRESS:- �tt�5 1J�_1 S� PERMIT SR#: � ` <br /> aO a 7140 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby af"m that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division <br /> 3 of the Business and Professions <br /> roofesslionns Cade and my license is in }hill force and eRect. <br /> License f�: r )r-)7.)`t V Explraden Date: t 1� <br /> Date: Contractor: h�- <br /> Signature: �C� <br /> Title: <br /> Panted name: r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of th�foilowing declarations: (CHECK ALL THAT APPLY) <br /> I have ane' will maintain a certificate of consent to self.-insure for workers'compensation,as provided for Gy <br /> Sectior 3700 of the Labor Code,for the performance of the work.for which this permit is iasuad. <br /> Il <br /> have and will maintain workers'compensation insurance, as reculred by Section 3700 of the Labor Code, <br /> �� or the performance of the work fcr which this permit.is issued. My workers' compensation insurance <br /> carrier ar+d poiic ( <br /> y numbers are: <br /> Carrler: ��t S } l S - PoncyNumber, <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 becorne subject to the workers'compensation laws of California, and .gree that if I <br /> should become subject to the workers'compensatlon provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: 7 .6�! Signature: <br /> Printed Name: <br /> WARNIN;: FAILURE TO 9ECUR9 WORKERS' COMPENSATION COVERAGE 1$UNLAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL F1NES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> DIO4 To'114E COST OF 3TOS OF THE LABOR CODE. <br /> EEREST,COMPENSATION,INTATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED ORIN <br /> I, �,�:'� (C-87 licensed authoMsed reprmantattve),hereby <br /> ti <br /> outhori=e <br /> to sign thin San Joaquin county Well Permit Application on my behal I understand this tuthorizatlon Is valid for <br /> ono(1)year and is limited to the work Pion dated on the front page of this application. <br /> 9-17-2000!MI <br /> E •d SI LSEtESz6 uaplam Rjew dTS = tO *,0 20 Dew <br />