Laserfiche WebLink
T P . 02 <br /> - Sep-07-01 12x20P ��. �,... ,� .,.- .� .. ....... ...... ... -- . -_ - <br /> Jtr <br /> if^4 <br /> /DO/ t l0oy Gr/- <br /> of <br /> r San Joaquin County Environmental Health Services, unit IV Well Permit Applicatlon Suppaomont <br /> ,002 355 <br /> JOB ADDRESS: 37 cP 4 ! /� h PERMIT SR#: o <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business and professions Code and my license is in fun force and effect // II <br /> License S. 177Gtf I Expiration Date, B / <br /> '7 m ba, <br /> !� n <br /> Dates 1.__.. Contractor: <br /> Signature: �` j � �� Title: �rF� <br /> i <br /> Printed name: o/�rr ,f <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 /> A I have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code, <br /> for the performance Df the work for Which this permit is issued. My warkers' compensation insurance <br /> Carrier and policy numbers are <br /> Carries T' e' !•s Nat _Policy Number: (�✓C F, l - $l7 <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 California. and agree that if I <br /> should oecome subject to the workers'compensation provisions of Section 3700 of the Labor Code, 1 shall <br /> i <br /> forthwith comply with those provisions. <br /> DaSignature: r f_Date: O � �- <br /> Printed Name: �jtl•1 /t 6M <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE is UNLAWFUL,AND SHALL SUQJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PADDITION <br /> ITTO TO HE COST OF LABOR OFCOMPENSATION.INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> ROVIDED FOR <br /> / � /� I (signature ofC-57 licensed authorized.sPresentative), <br /> •- <br /> hereby authorize(print name) ;,t el /tA uCJ� rt <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 limited to the work plan dated on the front page of this application. <br /> S-17-2000 1 MI .....-.. <br /> * 1UIHL PRUE.02 ** <br />