Laserfiche WebLink
J.K) (AJ <br /> San Joaquin County Environmental Health Services, Unit IV Well Permit Applica ion Sup <br /> JOB ADDRESS: O Rk X D W PERMIT SR#: 38 ZZ <br /> LICENSED CONTRACTORS DECLARATION (LCD) i <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#: //� O 7 o 7 Expiration Date: <br /> Date: / Co�ntractEor. - <br /> Signature: j <br /> Printed name: I" I11�'14 1 1 )a <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 /> �Ihave and will maintain workers' compensation insurance, as required by Section 37p0 of the Labor Code, <br /> ii/ rpoor the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy <br /> numbers are: <br /> Carrier: i / Policy Number: <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 compensa ion rovisions of Section 3700 f e Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Date: Signature: <br /> ��p.0' Printed Name: <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 THOU;AND DOLLARS <br /> ($100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEE'=S,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 370066,OF/THE <br /> ,(JLABOR CODE. ' <br /> (signature ofC-57 licensed authorized representative), <br /> hereby authorize(ilrint name) d _ "YJ/>7i�J�t. - j ' <br /> to sign this San Joaquin County W-011 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 /> 5-17-20001 MI _ <br /> i <br /> did STLSEIESZ6 uaptem Rue" dBSIEO 40 11 unC <br />