Laserfiche WebLink
08/05/2003 13:14 FAX 1006 <br /> /7L�G2� <br /> San Joaquin County Environmental Health Department Unit IV Wall Permit ApplicatiorCS�up�plement <br /> JOB ADDRESS: /?� E 1 4H46AX 4• PERMIT SR#:,O3 !`ay <br /> LICENSED CONTRACTORS DECLARATION ( Q) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 70p0)of Division <br /> 3 of the Business and Pmfessions Code and my license is in full force and effect. <br /> License 0: Q1t7�04` Expiration Date: <br /> Date: Contractor, /Jfl7�2yN � D/L�iC��b -TN7�G . <br /> Signature:� �n. ���+^— Title: <br /> Printed name: ST�7 ✓ Ba✓z•3 it <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 seff-msure 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 /> 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 this permit is issued. My workers' compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: Y�5r e(141:7 hA/5 - e4- Policy Number: <br /> I certify that in the performance of the work for which this permit Is Issued, I shall hot 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 workoira`compensation provisions of Section 3700 of the Labor Code, I shall <br /> �'f,/,forthywith comply with those provisions. <br /> Date:l '(O l/(�7 / 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 /> ($700,000.), 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 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I. (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this nuthorizatlon is valid for <br /> one(1)year and Is limited to the work plan dated on the front page of this application. <br /> e-29-02 1 MI <br />