Laserfiche WebLink
JUN 15 2004 10: 42RM WP LASERJET 3200 p. 2 <br /> nbiiitirnd4 09:07 abi33a33 <br /> FIFTH FLOOR, PAGE E3 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (L_CjD <br /> I hereby affirm that l 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 farce and effect. <br /> License#: �-� Expiration Date: 3 " <br /> Date: <br /> Signature: Title:. <br /> Printed name: �� pl <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 far 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 /> -11 have and will maintain workers'compensation insurance,as required by Section 3700 of the Labor Code, <br /> Tor the per°ermance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier. s`I�. _ Policy Number: 2— 'Vj oa J <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 subject to the workers'cornpensadon laws of California,and agree that if I <br /> should become sublectto the workers'compensatio ro • 1 s of Sectl 3700 of the Labor Code,I shall <br /> forthwith Comply with those provisions. <br /> Expiration pate: i Signature: <br /> Printed Name: r'LS �f V�hef <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (Stoa,000.),IN ADDITION TO TUE COST OF COMPENSATION,INTEREST,ATTORNErs FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37as OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ? (signature cfC47licensed authorized representatve), <br /> hereby authorize(prirrt name}`'ln'1_V � 4 S&C m ta-r Sr(�f <br /> to slgn thin San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(i)year and Is limited to the work plan dated on the front page of this application. <br /> 8-2582 I MI <br /> END 29.02.001 <br /> 9/30u:003 <br />