Laserfiche WebLink
- -------- --- -- <br /> San Joaquin County Environmen ealth Department Unit IV-Wall Permit Application Supplement <br /> JOB ADDRESS: leu Bel) PERMIT SR#: Ap 500S <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provis' ns of Cha Iter 9(commencing with Section 7000)of Division <br /> 3 of the Business and Professions Code and W license is in ull force and effect. <br /> License# Expiratior Date: <br /> Date: ontractor <br /> Signature:_ _Title: <br /> Printed name: <br /> WORKERS' COMPENSATIC N DECLARATION <br /> 1 hereby affirm under penalty of perjury one of the following de clarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-ins u workers'compensation, as provided for <br /> by Section 3700 of the Labor Code,for the performan the work forwhich this permit is issued. <br /> _I have and will maintain workers'compensatio insurance. as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which t permit is issued. My workers'compensation insurance <br /> carder and policy numbers are;/ <br /> Carrier: j(/� Policy 4umber: <br /> I Certify that in the performan of th work for which this I ermit is issued, I shall not employ any person in <br /> any manner so as to beco subject to the workers'coml ensation laws of California, and agree that if i <br /> should become subject to a workers'compensation prop isions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with th se provisions. <br /> Expiration Date: Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION I'OVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP'O ONE HUNDRED THOUSAND DOLLARS <br /> (S10,000),IN ADDITION TO THE COST OF COMPENSATION,IN-EREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t, (sig isture ofC57caned atrM_orized representative), <br /> hereby authorize fprint name) \T �(•jL�- <br /> to sign this San Joaquin County Well Permit Application on my b ihalf. 1 understand this authorization is valid for <br /> one(1)year and is limited to the work plan dated on the front pal;r of this application. <br /> B-29-021 MI <br /> Eno,a-oz-eoI <br /> N221(w <br />