Laserfiche WebLink
I -- <br /> R6/S4/2984 09:07 2094693433 FIFTH FLOOR rr::ur: vo <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SRiY: <br /> i <br /> i <br /> LICENSED CONTRACTORS DECLARATION (L_ CD) I <br /> I hereby affirm that I am liceised under the provisions of Chapter 9(commencing with Section 70100)of Division <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> Incense;M: Q , D Expiration Date: <br /> Date: Contractor: <br /> i <br /> Signature: Title: <br /> Printed name: <br /> WO KERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pequry one of the following declarations: (CHECK ONE) <br /> I have and will maintain a certificate of consent to self•Irtsure far workers'compensation,as provided for <br /> I j �/ by Section 3700 of the Labor Cede,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 Labor Code, <br /> for the performance of the work for which tnis permit is Issaed. My workers'compensation insurance <br /> i <br /> camer and policy numbers are: <br /> Carrier. ( �1/ �! Policy Number: <br /> I certify that in the performance of the work for which this per,^nit is issued, I shall no!employ any person in <br /> ary manner so as to become subject to the workers'compensation laws of California,and agree that if I <br /> shou'.d became subject to the workers'compensation provisions of Section 3700 of the Labor Coda,I shall <br /> forthwith comply with those previsions. <br /> i <br /> Expiration Date: / OS Signature: <br /> Printed Name- <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFLL AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (StOD,000.),IN ADDMON TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGE'S AS <br /> PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE. <br /> AUTHORIZATION FOR/O,/TH�IER-rTHAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ��� )a.2�1A � (r v (signature afC-57 ric"ssJed 2uthorized representative), <br /> hereby zuNioriza(Pnrrt name �PrrmitAp' caUo <br /> to sign thlz San Joaquin County behalf, understand this authorisation Is valid for <br /> one..(1)year and Is limited to the work pian dated on the front page of this application. <br /> H-29-02 I Ml <br /> I <br /> f3xD 2 .02-001 <br /> o/3LYsr�03 <br /> �/L d4¢D0�3 r <br /> I <br /> 7 'cl <br />