Laserfiche WebLink
San Joaquin County Environmental Healthy Services, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS:Abl� @kGronflifl .l PERMIT SR#: 23 <br /> 7�5V_ <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that i am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division <br /> I <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> i <br /> Llcense#: _CIS77 �6� Expiration Date: / <br /> Date: _ Con attar: o <br /> Signature: Title: <br /> Printed name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the Ibllowing 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 /> T Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> tKI 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: Ear-, Policy Number: (4. ©000 wl .5 <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'compensation laws of Califomia, 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 /> i <br /> Date: Signature: <br /> Printed Blame: <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-3 FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 37M6 OF THE LABOR CODE. <br /> ` 1 <br /> "11)Pe (C-57 licensed authorized representative),hereby <br /> authorize SCa t" �4�A. Mill (sem <br /> -r— <br /> to sign this San Joaquin County Well Permit Application on my behalf, l understand this authorization Is valid for <br /> one 1 year and is limited to the work an dated on the front page of this application. <br /> E0 3cJdd i"}a✓)yi� H1�I� 6EVE89060Z 6Z:9T RRR7/l T/Ra <br /> vA abed `ZZ:B 00-8G-bnV `ZOEO EVC SZ6 .` 'auI `GutTsal 'g buzTTTJQ bbau0 :A9 Tuag <br />