Laserfiche WebLink
Nov. 17. 2006 11 :39AM Ad ed Geo Environmental v No. 6823 P. 2 <br /> San Joaquin County Environmental Health Department Unlit IV Well Permit Application Supplement <br /> JOB ADDRESS: j5­/,J 5- S-A llL� 7"k S+ PERMIT SR*: <br /> ZGirr m rop. CA <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 Business and Professions Code and my license is in full force and effect. <br /> License A: c--57-P-- 67Z6 ( 7 Expiration Date: 6r '3 D b 7 <br /> Date: t I ( y J 0 G Contractor <br /> Signature: Title: y <br /> Printed name: G Z-olz GZ-- <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> —1 have and will maintain a certificate of consent to seH-fnsure for workers' compensation, as provided for <br /> by 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 insurance, as required by Section 3700 of the Labor Code, <br /> for the pertonrianee of the work for which this permit is Issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Cartier: ZA (� J Lk- I iQ5• GO Policy Number. N 6 – 0c,7.-c56/ <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 so as to become subject to the workers'compensation laws of California,and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> � 1 <br /> Expiration Date: L b 17 Signature: <br /> PrintedName: G�G <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 /> (ttoo,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES.AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> I � Q (signature ofCS7IIcensed authorized representative), <br /> hereby authorize(print name) (Z®be✓�t <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(t)year and is limited to the work pian dated on the front page of this application. <br /> 8-29-02 I MI <br /> EHD 2M2-001 <br /> SMIM <br />