Laserfiche WebLink
Oct 18 04 11 : 21a WEcTEX (9191 373-0548 p. 2 <br /> v \a/ <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supptemmt <br /> JOB ADDRESS: I-7-760 ERS1- Fiwy 4 PERMIT SRA: W_ dc1 <br /> Siwk4zn, CA <br /> LICENSED CONTRACTORS DECLARATIONL( CDl <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 /> Licenser r S 7# S 5 21 9 8 Expiration Data: 9 /3 0 /0 5 <br /> Date 1 0 18/.04 Carigactar: WESTEX <br /> Stgnawra: ��f2(i-=-o -`LI' L Title: General Manager <br /> Printed name: Gordon Jen en _ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of PerpW one of the following declarations: (CHECK ONE) <br /> _1 have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for <br /> by Section 3700 d the Labor Code,for the performance of the work for which Sus permit is issued. <br /> I have and wilt maintain workers'compansaliun insurance,as reglured by Section 3700 of the Labor Code, <br /> for the performance of the work for which this pormlt Is lssued. W workers'compensation insurance <br /> tamer and policy numbers are: <br /> Canter: State Fund PolicyNomber., 1569784-2004 <br /> 1 certify that in the performance of the work for which this permd is issued. I shall not employ any person in <br /> any manner so as fo become subject to the workers'Compalsation I of California,enact agree ttrat it I <br /> should become subject to the Workers'Compensation Provisgna of 3700 of th$'Lebor Coda,i shall <br /> forthwith comply with arose provisions. ,. . <br /> Fcplra0oa Data: c/01 /0 5 Signature: <br /> Printed NameGordon Jensen <br /> I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND Clint.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (St ea,goo.),Si ADDITION TO THE COST OF COMPENSAIRM INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR 0TH R THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, r' r7 To n S n (signature ofCS711r sedauthmi<ad repreaenheve), <br /> hiaeoy authorize(pnnt na") <br /> to sign itds San Joaquin County Well Permit Application on my behalf. 1 understand this authorization is valid for <br /> am(1)ye,,and is unrated to the work plan dated olr the front page of this application. <br /> 8-2&02 1 NI <br /> P}tD 29-02-0O1 <br /> (✓12/Od <br /> EB/Z9 39Vd 531VIOOSSV 63(1309 7EOZ-98L-9I6 Z5:0I 00OZ/8I/9I <br />