Laserfiche WebLink
07/31/2000 08: 59 1916633_,F, 1 CASCADE DRILLIC NC _ PAt7E 01 <br /> J1JL-51 <br /> –eo M�?rr .uw - <br /> -�- �.. .,m ...,..._.._ n Su lerrlan <br /> - gin Joaquin County PnVironM*htltl Health Services,Unit IV Wait Pmrmlt App D <br /> : s � a 12_SPE <br /> �.�1.�.-���--1--- RMfT SRN' <br /> JOB ADDRESS _ - <br /> I <br /> LICENSED coM-rRacYoRs DECLARATION WQQ) <br /> j ! herebi+ affi;m"t i am!icsns+3d v+rdBr t"+la provi5ic tti5 of Chapter 9 {commerlang with sect;on 7000)of Division \ <br /> 3 of the BUSiI1QGS andProfessions Cope and "I1y ll(;rdn$e 1 in full force and effect. <br /> L icensa E,KPlratlon Oats. _!�c�!�—ti! �_.. V <br /> id V Contractor ... . <br /> + Date. _� ..5 --- -C <br /> j <br /> Title.- <br /> signature: <br /> i Printed nail}s: N&('� -- <br /> WORKERS' COMPENSATION DECLANATICIN <br /> I hereby aMrm under F©nalty of perjury one of the foUawing declarations (CHECK ALL THAT APPLY) <br /> I have and wil� mal.)Iain a CedifiGE a' of consent to sett-ins;re for workers'con,pe <br /> nsdt.,)n as provido(t for oy <br /> y2Soctipn 3n700 of the Lab .)or Code, for the perforlTlatjoe of the wofK for which tris perm4 4sued. <br /> and will maintain workers' COMPWIsation insurance, as required by Section 370 of the Labor Goias, I <br /> rae <br /> Mr the pri formr-t.nce c4 trio wank for whioh this permit is issua:J My workers'oorrnpensatwn insurrance <br /> cdrner and policy io nbor's are :,p S <br /> 111. <br /> Carrior; .. f <br /> -� °��L G_6�_ Policy Numbur: _P_ CY W �3.��--� <br /> I C010y Uiat in the performance of the work far which tnis psrmit'.s issued I shall not employ any p6Ytlon in 9 <br /> �- workers'comperlsatiorN. laws of Cal3Qrni&. a' ,, a;y.�e that if i <br /> ary rt>Wnner so as:o cecome subypct t4 the <br /> ronould become subiact to the workers' c, rmperls8trpn provisio 5 of Beavon 3700 of tris i at,or'Code, shall <br /> to(, <br /> hwilh co-1F'y w!th thc)se previsions <br /> 1 <br /> Dat.: <br /> Printed Name: <br /> WARNING: {=Ail.iJkE TO SECURE WORKERS' COMPENSATION COVERAGE 45 UNLAWF4""L.. AND SHALI.SUBJEt,T <br /> AN EMPLOYER TO WUMINAL PENALTI&$AND CIVIL FINE$UP TO ONE HUNDRED THOUSAND DOLLARS <br /> PROV000.) FOR <br /> IN I ON OTO TAE:N 37G6 OSTHEF;CMP COATION,INTERL-ST,ATTORNEY'S FEE$,AND DAMAGE$AS 1 <br /> OF I <br /> licensed auttloriied repriiii,sel'1'tefivpl,)WOW <br /> to sign this Ban Joaquin County W411 Plarmlt Application or,my behalf, I understand this iutl'1061 9n Is valid for <br /> one 1 ear an4 is lirrnitrsd to the work 1311 oated oo tho front PNO <br /> n <br /> s <br />