Laserfiche WebLink
Sep-07-01 12 : 20P P. 02 <br /> rf <br /> jam¢ 100/ f IODZ i f/ <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Applicatlon Supplement <br /> C 4�� � ,h :oDz 355 <br /> JOB ADDRESS:371-Llnra Ph P / 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 Rusinoss and Professions Code and my license is in full force and effect <br /> License t: 17 760 I_ Expiration Dale:__- 1"9 Z10/O <br /> _ ',, , <br /> Date. /f Ai Contractor: ��,ovCS ,[/YI I(j awa d �6cMD <br /> Signature: Title: C'FC7 <br /> Printed name: �Ot r1 r <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 wiil 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 nurnnOers are'. <br /> Carrier: <br /> -54,Z4t N! , p.� _ Y Polio Number: r (,,)CC 6441 - e/7 -0 D <br /> ._ <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, I shall <br /> forthwith comply with those provisions. <br /> Date. / O / _,. Signature: <br /> Printed Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (Sf D0,0D0,), IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN sECTION 3709 OF THE LABOR CODE. <br /> 1 (signature ofC-571laensed authorized representative), <br /> hereby authorize(print name) /CYPSq /tgNCil t L -FA Irr*rttL17�..YS <br /> to sign this San Joaquin County Well Permit Appileation on my behalf. I understand this authorization is valid for <br /> one till year and is limited to the work plan dated an the front page of this appllcstign- <br /> 5-17-20001 MI .._._.._..._ <br /> we I U I f1L PRUE.02 � <br />