Laserfiche WebLink
FROM : West Hazmat • FAX NO. 19166388613 �ep. 19 2001 09:41AM P2 <br /> kA <br /> 913Bt2001 09:31 209abaa43'j rIF7H FLO[7R FAGF0.1 <br /> , r <br /> { <br /> I <br /> San Joaquin County Environmental Health Services,Unit IV Well Permit Application Supplement <br /> JOR ADDRESS: IS9,0,b SpredaCc, PERM11 SRM zjj�P-7- g•b2 <br /> Oo 7, 9- <br /> LICENSED CONTRACTORS DECLARA IONL(_CDl <br /> t <br /> I hereby affirm that I am licensed under ilia provi.ions of Chapter g (ocirrimani ing with Section 7000)of Division <br /> ^t 3 of the Business and Professions Code and my license is In full force and a el. <br /> _._Lxpiration Date:__ <br /> pato:,,_/L D I Contracctor: 096r__ .►Y~_t�LsJ.lr,�y.. �.oC . <br /> :.r.;l Signature;,•_/ ( Title: i bJd(.>t(_.. <br /> Printed tramp: A <br /> R i . — <br /> ( � WORKERS' COMPENSATION DECLARA ON <br /> I hereby affirm under penalty of parjury one of the following declarations: (CH CK ALL.THAT APPLY) <br /> halo and will maintain a certificate of consent to self insure for workers ornponsation,as provided for by <br /> Section 3700 of the Labor Code,for the performance of the work lal whit this permit Is Issued. <br /> -� I have and will maintain workers'compensation insurance,us required by 4ectidn 3700 of the Labor Codo, <br /> for the portormence of the work for which this permit is issuad. My works 'compensation Insurance <br /> carrier and policy numbers are: <br /> Carrier:_ �1zb7 y FS-i✓6 <br /> ., ...Policy Number: <br /> " <br /> —I onriffy that in the perrorrnanee of the work for which this permit is Issued, I shnil not employ any person In <br /> 4f M any manner so ns to become subject 10 the workers'contponsation laws a California, and agree that If I <br /> should become subject to the workers'campenaatiem provisions of Secge 3'100 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> l; Date: OS- yS-Uf - 7f l x <br /> Signature: r' „ / .. /: � �C _ <br /> Printed Namef G a>cx'�lc�l r' <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS U LAWFUL.AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAI.PENALTIES AND CIVIL FINES UP TO ONE HUNDR p THOUSAND DOLLARS <br /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTOR EY'S II EES,AND DAMAGES A3 <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> (signatureofC-5711cnsedauthorized mro <br /> representative). <br /> hereby authorize(print name) Lf�i-a . _.._., ..CC1 •ICs .—. ��.— <br /> to sign this San Joaquin County Well Permit Application on my behalf. I utldersta id this authorization is valid for <br /> I' <br /> one(t)year and Is limited to the work plan dated on the front page of this applica on. <br /> 5-17_2000/M1 <br /> .0 <br /> v <br />