Laserfiche WebLink
Dec 14 00 08:22a ris Fisch (2 41772-3571 P. 2 <br /> C:e i?. 00) 1 Hkl GNCDR :ARIH TECWNJ;_-'D IES Pi,.3416 F .. - <br /> San Joaquin County Environmenttal�`Health)Services,'Unit IV Well Permit Application Supptetne t <br /> JOB ADDRESS: Av,52 Its• c>7Lll?�.SL�(G'lS Qt- PERMIT SR#: ,V! <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> i <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Divislon l <br /> 3o the Business and Professions Code and my license is in full force and effect. <br /> License 9: /��?i iso 5 -Expiration Expiration Date:_ /"a3/-o 4;z— <br /> Date: <br /> ;Date: l cp`/ _(�� _Cont r ctor: __/f S�t" f-_n ill din A)M e,0/15�//J <br /> I <br /> Signature; Title: 622221,(A <br /> Printed name: r 1 /r �S C� -f l i <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by <br /> 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 Coee, <br /> for the performance of the work for which this permit is issued My workers'compensation insurance <br /> carrier and p�1 ;y numbers are'. <br /> - 3Carrier: PolicyNumber: l~ , C <br /> 00 <br /> I certify that in the performance of the work for which this permit is issued, I shalt 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 /> I should become subject to the workers'compensation provisions of Section 3780 of the Labor Code, t shall <br /> forthwith comply with those provisions. <br /> Dats: /' -/.3'dC� Signature: <br /> Printed Name: <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 /> ($100,000.),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. I <br /> i, ,, (I VI <l (C-57 licensed authorized representative),hereby <br /> authorize -- --- _ j <br /> i <br /> to sign this San Joaquin County Wall Permit Application on my behalf. 1 understand this authorization is valid for ! <br /> i <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> e <br /> i <br />