Laserfiche WebLink
Nov 27 2007 2: 24PN BOART LONGYEAR 530674.5712 p• 2 <br /> SM001 <br /> Sart Joequin Counter Environmental HatlriCh Department Unit IV Well Permit A.pplioatlorl Suppiernerut <br /> JOB ADDRESS: 1444151` 5AL.iP1wk 51, 5" PERlMT OR#: <br /> LICENSED CONTRACTORS DECLARATION I <br /> I hereby atnrm that I am iterieW under the provisions of Chapter 9(comrneacirtg with Sedon 7000)of Divlslat <br /> 3 of ft Businees wd Professions Code and my E is in full 166 and offeck <br /> License j ERVirationDet ' <br /> ©ale: corsar <br /> i <br /> Sip Me: <br /> 61701/ <br /> PdntAd name: LIE <br /> WORKERS'COMPENSATION D CLAIRAMON <br /> I hereby*Irm under pa"Ity of penury one of the following declarations: (CHECK ONE) <br /> —I have and will maintain a ceffrAc of consent to salT•lnsureler woftrd compenestion,its provided for <br /> by Section 3700 of the Labor Cade,for the performance of the{work for which thio pomA is issued. <br /> d. <br /> have end mitt maintain workeW compensation insurance,as(required by Section 3700 of the Labor Cade. <br /> for the performanda of the mark furwtdch this permit is Issued INl warkem compensation inaurence <br /> carrier and policy numbers are: <br /> Carrier: ` Policy N I bw-. 2 2 CU F— <br /> I certify that in the per lormance of the work for which this pem�+itis issued,16hall not ennploy any person In <br /> any manner so as to becorne subject to the workers'compensation Iowa of Cefrfw6n,end agree Utat d I <br /> should become subject to the workers'compensation provisiolu of Saetion 3700 of Me Labor Cade.I shall <br /> forthwith comply with those provi3ions. <br /> Expiration Data, ])-3 U—O 2� ftnatum <br /> Printed Name: <br /> WARNING:PAJLURE TO SECURE VVOFtiQGRIl3'COUPENSATION 001f6RA E is UNLAWFUL.AND SHALL SUBJECT <br /> AN IMIDYM TO CRIVAWAL PENALTM AND OWL FIRE*UP TO ONE HUNDRED TNOUSAMD DOLLARS <br /> 01410.000.1,IN ADOnXM TO THE GMT OF COMPENSATION,INTEREST,ATTdRNEY'S FEES,AND DARIMES AS <br /> PROMDED FOR IN 3EC710H 3106 OF THE LAWN CODE. <br /> AUTHORIZATION FOR 07WER THAN C.W SIGNING PERMIT APPLICATION <br /> 1, W cei ofC-V 11 need Pvthorlmd repnmerdattve), <br /> hsaby auehorIU(Print narns) <br /> to sign arta But Joaquin Counlr Well Pervert Appiftlilon on my beh i f. 1 understand this atr1hortnVon Ix valid for <br /> ons(1)ysarand Is limited#4 the workplan dated on f the nt page'ftttis awleavam <br /> 8-s9-02111M <br /> s��-oa•oar <br /> tir�lb4 <br /> Z0JZO 3E)Vd dI-wO ON Sfllt}2i1.5 50099L90ES ZE:t0 Le0Z/LZlti <br />