Laserfiche WebLink
San Joaquin County Environmental Health Serv' s, Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: (p(o32 fr e30 �,gSU PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000) of Division <br /> 3 of the Business and PiofeessionsCode and my license is in full force and effect. <br /> License #: �� 0`)L-01 Expiration Date: ` �36-02- <br /> Data: 1 f� [Contractor: ks 191LL/�/t /Vn�Jn//'t/ �dJ <br /> Signature: """"` Title: <br /> Printed name: t/✓R� a �{rl/M�Sn 11 <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I have and will maintain a certficate of consent to sett-insure for workers'compensation,as provided for by <br /> Section 3700 of the Labor Coda,for the performance of the work for which this permit is issued_ <br /> XI 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: O n qq <br /> Carrier: _�I.' r_ _ � P�770 TA '.&4olicy Number. WC 11 <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 bacoms subject to the workers' compensation laws of Callfomia, and agnea that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> forthwith compy with those provisions. <br /> Date:. 6—S O i Signature: t/( A. , <br /> Printed Name: Gr mA <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDRED THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOUR IINJ SECTION 3706 OF THE LABOR CODE. <br /> 1, /l/u� �l�n� (signaturt ofC-9777 lice"ad authorized repreeentstive), <br /> aereby authori2e(print name) O/, L-.FA P1ZlcFE�/T'x'7-1y"11 <br /> to sign this San Joaquin County Well Penult Application on my behalf. I understand this authorization is wlid for i <br /> one(t)year end is limited to the wore plan dated on the front page of this application. <br /> 5-17-20001 MI <br />