Laserfiche WebLink
p. l <br /> P6 El'57 `XrT N <br /> O <br /> no <br /> � <br /> San Joaquin Coun nvironmenntta_l Health()apartment Unit IV Well Permit Application supplemental <br /> JOB ADDRESS: ��7 �'�� PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION ( } <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect_ <br /> License#: "�5`� 7 o C 57 Earp Date: f 01'�p j!O <br /> Date: �L7 Contractor: 1+,vvin4r2rnYNt iUN�S?alsSOCGCt,� <br /> Signature: /�---�� Title: r�__s <br /> Print Mame:�- ! i <br /> WORKEWS 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 <br /> provided for by section 3700 of the labor Code,for the performance of the work for which this <br /> permit is issued. <br /> (/ 1 have and will maintain workers'compensation insurance,as required by Section 3700 of the <br /> Labor Code,for the performance of the work forwhich this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: Policy Number. WCC-C4S-701 SSA <br /> I certify that in the performance of the work for which this permit is issued, i shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code,lshall forthwith comply with those provisions. <br /> Exp.Date: 8 l/1 t) 1O Signature: 7� <br /> Print Name: f tr`7t <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIViL FINES UP TO f100,000,IN ADDITION TO THECOSTOF COMPENSATION,INTEREST, <br /> A77ORNEY S FEES,AND DAMAGES AS PROV40SO FOR IN SECTION 8706 OF THE LABOR CODE. <br /> ._,.AUTH,•QR�ZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> 1. )► "� (( L' _(signature of G-67 licensed authorized representative), <br /> hereby authorize(print name) BILtYAM R©IZ(E_ to <br /> sign this San Joaquin county Well Permit Application on my behalf, t understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> errerQza�t � <br /> EMQ2481 tt/SU7 <br /> Y191 CERMf(MF <br />