Laserfiche WebLink
_ 02 /08/ 2003 THU 08 : 02 FAX <br /> I <br /> San Joaquin County Environ``mentatHaa).th�.pServices , Wnit IV Well Permit Application Supplement <br /> JOB ADDRESS :w q) e �f r / l}� ` PERMIT SR#: <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 Busin�e7s�s1 and Professions Code and my license is in full force and effect, <br /> License #: lrGf �'7 Expiration Date: <br /> Signature• I - /Qf/,• � - Title: <br /> 11 <br /> Printod name. OJn - <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm urder penalty of perjury one of the following declarations: ( CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self-insure for workers' compensaticn, as provided for by <br /> Section 3700 of the Labor Code, for the performance of the work for which this permit is issued, <br /> I have and will maintain workers' compensation insura.9ce, 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: <br /> �lrll�l� � Policy Number: � I � T � —�� <br /> CdrrieT' �„ - <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 se as to become subject to the workers' compensation laws of CalifWnea, and agree that if I <br /> should become subject to the workers' compensation provisions of See:ion 370U of the Labor Code, I shall <br /> forthwith qOmqfy with those provisions. 1 <br /> Date : = Signature: .�(. � � �^ 4A, <br /> Printed Name: <br /> WARNING : FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT I <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($1001000. ), IN ADDITION TO THE CAST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES A9 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ljj ( C-57 Ii nsed authorized representative), hereby <br /> authorize I <br /> to sign this San Joaquin county Well Permit Application on my behalf. I understand this authorizatfon is valid foT <br /> one (1 ) year and is limited to the work plan dated on the front page of this application, <br /> VdOr{.� 19c7S "11 GG6 1 -. /0-7) 1 <br />