Laserfiche WebLink
10/19/2004 10:30 FAX � � v X 00 2 <br /> San Joaquin County Environmental Health Deepartmee t Unit IV Well Permit Application <br /> Supplement <br /> JOB ADDRESS: JV uC / /�� PERMIT SR#: ooas <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division I <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: (15 AZO Y aZ Expiration Date: in / 51 <br /> Date: Contractor: <br /> Signature: Title: <br /> Printed name: <br /> WORKERS' 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 provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, <br /> have and will maintain workers' o_+mpersation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier, til ( Alp /V lie 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 subjtset io the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: (P�:_ Signature: <br /> 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 THOUSAND DOLLARS <br /> 15100,000.), IN ADDITION TO THE COST OF COMPENSATION, INTEREST,ATTORNEY'S FEES, AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION <br /> 1 FOnR CInTHUER�THAN C-57 SIGNING PERMIT APPLICATION <br /> I, B A_ , L4 /A dp// ��i ,y1� (signature ofCS7 licensed authorized reprresenttativ�e), <br /> hereby authorize(print name) WJ � (��ja12�✓l� 1 I ' f✓I v�w�"—. <br /> to sign this San Joaquin County Well Permit Applicationon— my behalf. I understand this;authorization is valid for <br /> one(1)year and Is limited to the work pain dated on the front page of this application. <br /> 8-29.02/MI <br /> EI{D 29-02-001 <br /> 6l20/n,$ <br /> Z -cl STLSETESZ6 uapTem RJew eDE = TT bD 61 1cD <br />