Laserfiche WebLink
04/30/2000 14:58 9255211494 UIRONEX Sr- P%:GE 02 <br /> 04/29/2008 02: 49 92537150 GEOCON - EA5T $A* PAGE 02/02 <br /> ja-�e__ Z <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Applications Supplement <br /> JOB ADDRESS: Z�JbJl9 S. «�4 PERMIT SIR <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed underthe provisions of Chapter 9 (commencing with Section 7000).Of17Ivinicn <br /> 3 of the Business end Professions <br /> Professions Code and my license is in full force and effect. <br /> License#: f C1Expiration Date: DS' 3[ • 09 1 <br /> Date (D�`artna,,, (( Contractor: �/1Cdf1(X <br /> X.0 <br /> Signature: / ,&C, 1 _ ttaL ffi Title: 6P6CC fncwa�ef- <br /> Printed name: l A( 1wa Darn atrh <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> ✓I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Soctlon 3700 of the Labor Code,for the performance of the work forwhich this permit is issued. <br /> 1 have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issuod. My workers'compensation insurance <br /> carrler and policy numbers are: U/cb�y <br /> Carrier: ( Policy Number: <br /> 1 certify that In the performance of the work for which this permit is issued, I shaft not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that If I <br /> should become subject to the wcrkers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provlaions. <br /> Expiration Date:-P&Z 9lgnature: <br /> Printed Name: o1 1L.aLQrrh <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($fassaa.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 9708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, L.G�+� a ,v�'r'�°`-`� (signature ofG97 licensed authorized reprona"Movq), <br /> hereby authorim(print name) QtCK —0P CM K CppCt,ayalV11s <br /> 10 sign this San Joaquin County Well Permit Application on my behalf. i understand this autharrzation Is valid for <br /> one(1)year and is limited to the work plan dated an the front page of this application. <br /> a-29-021 MI <br /> EHD 7.a•n2�a7 <br /> V2210a <br />