Laserfiche WebLink
v-al ..v. rvv.• a••� vv _r ,.a.. day i v— vi'...c..�., a a. 0 _ <br /> v T^� �ikrWtjl:Permii Application SI1I?P4+ment <br /> : <br /> �h�nr_a". fie•_�.._.`_:Fh:1.r� .Ss� <br /> San+loagUil+:::ouiircy� <br /> JOB <br /> a�� '�_rLILfi <br /> l. �L ..�aTl�N (-LCD) <br /> i <br /> of Division <br /> I rrereby atfirr�tr+;:r! ar•::-=,near+ lJr,l�ir rhP r•]+`f:G�, _r^hal::'r mri <br /> f.,,' y :,rite Section 700C) <br /> 3 of the HUs,,+ :73 a:-. protess'-cnc::ode and my ;:�!i!rMG:a;n fullforce anG effect. <br /> rv� <br />` (-icense �al�'-'� Expiration Date: <br /> Date: _,tea L _ _ y-_:n...•:W --- '�•-. „� _ <br /> $'+gt'1 Sture: CAaalt�ft <br /> �1 �•j�'�=tJ4. _. ._._..___._Title: <br /> Printed dame: <br /> ► J <br /> wA,aia�w� rrr.a'.rn\:CaLY1M� M►!•'e�! i1if.'rl/"�li <br /> 'low fltlt,A VVrM►f'Ck�.7/+l ivk� VC:vV�11r'a l ly l� + <br /> Ik <br /> I hereby ai!3rr'+ of:*or)llry�).;r[tA'�`��!e'v'��`1 raclararions_ +ICFfECIt.ALL THAT APPLY} <br /> 1 have anCi wii: N.. �n.a]r�r3rs' i:i]inurrlSetlOn, as provided for e y <br /> for Pic_rr+•-:ormrv-,;e e!the W,;*.f+fr which this permit m issued. <br /> �Iv i havean wilF rnainYd in uimrLa�c'Crrmner!seginn in R!_f/11 r1r'P_ AS rr 111rt�ici hV Spr�tinn 3700 yr the Labor Code, <br /> i for the;ser r<<rancs crt'sfte u�.r:c fpr + t) :i;;Y„�l�,., ._.a tilt il. [a.y'i+<�ilt+_l a wrrlpensation insurance <br /> iI carhe:- numbers are: , r <br /> Carrier: '•-V-A r' 4L�}.� Policy Number <br /> V <br /> 4 certify that in the performance Of the work fes which this permit,is'issued, I shall not employ anq persch in <br /> any manner so as to:.u:c iT o :n.Isy):T%l tr14 a/rjka i s•zcmpensation laws of Cafifomia• and agree that if! <br /> Should noeame Subject t;;the f::nrkers' compensation pfovisions of Section 37rA of the Labor GQde. 1 shall <br /> forthwith comply with thoss proVisions. <br /> Delt6. <br /> Printed Name: <br /> i + <br /> i <br /> WARNING:FA)LURE TO SECURE WORRIERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN R MPLOYEIR TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDIMU THOUSAND COLLARS <br /> {�IDO,Delt3.), 1H,iDDMON 70114E COST'OF C'dMPENSATION;-tNTERESY,7ATTORNEY'S-FEES;AND DAMA4RE3,AS <br /> ' PROVIDED FOR 1N SECT;ON 37o6 OF THE LABOR CODE. � <br /> I X-571iceres a zed ntpre9entative)• hereby <br /> � r <br /> authorize <br /> to sign this San Joactuin County Well Permit ApplRcatlon on bchal',. I understand this authotiza►tion'ia valid for <br /> one(1)year and is limited to the work plan dated on the front pago of this application. <br /> tk <br /> f <br /> l <br />