Laserfiche WebLink
San.Joaquin County Environmental Health Department Unfit IV Welt Permit Application Supplement <br /> JOB ADDRESS: .57'W c J--or) PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hereby affirm that I am licensed under the pmvisiona of Chapter 9(commencing with Section 7000)of Divislon <br /> 3 of the Business and Professions CO(le and my license is in full force and affect. <br /> License ; C I ( 0 Expiration Date._ r -3� }(.P <br /> Date: — Contractor. Cat I <br /> Signature; 'Title: <br /> Printed name: 0— <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby'affirm under penalty of perjury one of the foilowing declarations: .(CHECK ONE) <br /> 11160 and will maintain a certtfc*to of consent to self4nsure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,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 perfamance of the work for which thts permit <br /> carflor and policy numbers are: is issued. My workers'compensation Insurance <br /> Carrier: 1`011cy Number. 6 Lpr i d15 I, <br /> I certify that In the perlbrmance of the work Par which this permit Is i8sued,f shall not C!M to an <br /> any manner so as to become subject to the vuorkers,compensation laws of Callfornia,and agree hat f i rson 3n <br /> should become subject to the y�ricers'�mpensatlan provisions f Section 370o of the Labor Code, I shall <br /> forthwith Comply wfth those provisions, <br /> Expiration Dats:5 I— Q(17 gignature; <br /> Printed Name: t Q <br /> WARNING:FAILURE TO SCOURS WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL.FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> 0100,000.),IN ADDfTIDN TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDI=D FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORI7namn" ) <br /> OR f?THER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, <br /> talgneture ofC-67 Gcnnsed authorized representative), <br /> hereby authorize{prin _ <br /> tosign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and is lirnitact to the work plan dated on the t1•nnt page of this apprcation. <br /> 8-29-021 MI <br /> EHD 25-�7.p01 <br /> 611710-0 <br />