Laserfiche WebLink
0 EL <br /> T 01 2003 3: 2GPM H' '_RSERJET 3200 P. 1 <br /> OCT. 1. 2003 1 01 PM CON~u RR EARTH TECH NO. 0402 P. 6 <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Applicatlon Supp►emjYJ <br /> JOB ADDRESS: �9 f ,4wy Sr. #,lvrrc4 e4 PERMIT SR#:�J 'c3 <br /> �y <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Seaton 7000)of Division <br /> 3 of the Business and 'Prroff�essions Code and my license is in full force and effect. <br /> License tf: (/SCO Tv 7 Explratlon Date: O d <br /> Date: �3 Contractor: /' (�JZ. 777, <br /> SFgnature: • !� itis: _1Qd -'a t_S64 <br /> Printed name: L/-4/ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> I have and will maintain a certificate of consent to self-Insure for workers' compensation, as provided for by <br /> Section 3700 of the labor Code, for the performance of the work for which this permit is issued, <br /> ave 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; C., -�7 Policy Number: � �C e9,2-/7 <br /> �eertify 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 tD 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 /> Date: 4 l' signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATIO COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000.),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 /> I. (C-57 licensed authorized representative),hereby <br /> authorize /r1KWg11fiU _ D'&Z ZPF <br /> to sign this San Joaquin County Well Permit Application on my behalf_ I understand this authorization Is valid for <br /> one(1)year and Is fimitad to the work plan dated on the front page of this application, <br /> 5-117-2000 l MI <br /> RECEIVED TIME OCT, 1. 3: 25PM <br />