FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

JUL 15 2003 4: 21PM HP IRSERJET 3200 P. 1 07/15/2003 15:00 CLAYTC OUP 4 3130302 � N0.561 P03 A01�11_ San J In County Environmental Health Department Unit iV Well Pe mit Application upplement JOB ADDRESS: f PERMIT SR#: 60 3�51v/ LICENSED CONTRACTORS DECLARATION (LCDJ I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division 3 of the Business and Professions Code and my license 19 in full force and effect License Mf S Expiration Date; Date: 7// D 3 Contractor,L�f Signature: �J Title: Printed name: WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations- (CHECK ONE) I have and will maintain a celtificne of consent to self-Insure for workers' compensation, as provided for bySection3700 of the Labor Code,for the performance of the work for which this permit is issued. -have and will maintain workers'compensation insurance. as required by Section 3700 of the Labor Code, for the performance of the work for which this pe(mlt is issued. My workers'compensation insurance carrier andpolicy numbers are; carrier, f d>V? Policy Number: I certify that in the performance of the work for which this permit Is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that if t should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with those provisions. Date: —7-11 5 ��Signature: Printed Name: WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND DOLLARS (S100,000.), IN APOITION TO THE COST OF COMPENSATION, 1NTEREBT,ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 370E OF THE LABOR CODE. AUT ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION / 1 de–sf— 18 sI nature of'C-S7 licensed authorized representative), heresy authorize{print name/ Dn�j to sign this San Joaquin County Well Pem+It Application on my behalf. I underswnd this authorization Is valid for one(1)year and is limited to the work plan dated on the front page of tris application.