Laserfiche WebLink
FROM : ResonantSonicInternational FRX N0. : 5396682429 <br /> Nov. 94 2994 95 : 99PIq p2 <br /> i f <br /> San Joaquin County Environmental health Department Unit IV Wsl( ,PermitAppiica73upplamontJOB ADDRESS: ( 3 C) N t1vYt1 ey Slwae�- peliMlT SR#:LICENSED CONTRACTORS DECLARATION LC <br /> I hereby afflnn that I am Ilcensed under the prvvlalons of Chapter 9 (Commatncing with Stiction 7000) of divWoh <br /> 3 of the Business and Professions Code and my license is in full force and Gffect- <br /> License #: _ B z z i 44 Expiration bate: t o y- _ <br /> ?_7" <br /> Date: I ��� Contraetor: - <br /> Signature; _ <br /> Title' <br /> Printed nem�� <br /> VU0RKr"k9' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratiohs: (CHECK ONE) <br /> I have and Wil maintain a nartlflcate of consent to selfdnsure for workers' compensation , as provided for <br /> by Section 3700 of the Labor Code, for the performence of the work for which this permit is issued. <br /> ,L'� I have end will maintaln 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 she, <br /> Carrion; 54 >t fft!- Jaz Pollcy Number: <br /> I cartlfy that in the <br /> performah ce of the Work for which this permit is issued I hall <br /> p s not employ an parson in <br /> any manner so as to become subject to Y <br /> ) the workeYs compensation laws Ws of California, and aeras that if I <br /> should become subject to the workers' 0ompenaaWn provisions of ewuUon 3700 of the Labor Coda I shall <br /> forthwith comply with those provisions, <br /> ExplratlnnDate: ?�///� Blgttatura: _�/�_� <br /> r <br /> Printed Nems: <br /> WARNINO: FAILURE TO SECURE WORKPRS' COMPENSATION IS UNLAWPUL, AND SHAM SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL PINES UP TO ONE HUNDRED THOUSAND DOLLARe <br /> (1!100,000,), IN ADDITION TO THC COST OF COMPENSATION, INTEREST, ATTORNEY'S F5ES, AND DAMAGES AS <br /> PROVIDED POR IN SECTION 3708 OF THE LABOR CODE, <br /> AUTHORIZATION PCR OTHER THAN C-S? SIGNING PERMIT APPLICATION <br /> 1, (signature OGZ7 Ilcensed authariced representativa), <br /> hereby authorize (prtnit name)_ 2)6n.-- /r _ <br /> to sign this San Joaquin County Well PannitApplication on my dehaif, I understand this arlthortxaUan Is valld for <br /> one (1) year and is limited to the work plan dated on the front page of this application. <br /> 8u2"2 / MI <br /> 9RD 2902.001 <br /> 5/22/04 <br /> 2 ' d 276 ' ON 0��021 '8 "1"I�t1Qa�b.1 WH9E : 'rl: b902 ' b ' AON <br />