Laserfiche WebLink
04/23/2007 MON 13: 15 FAX 9002/002 <br /> Apr 23 07 12:01p Musco Family Olive Van 836065'0 p.2 <br /> � l� <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: '`� b ✓� �yGOw, PERMIT SR#: 6)05- � Ac"J2S26 <br /> —Zg 3o5 s. .� oD 5 a 732- F ,Z <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirmthat I am licensed under the provisions of Chapter g(commencing with Section 7000)or Division <br /> 3 of the Business and Professions Code and my license is in full force and effect <br /> License#: '7 2 0 9 6 L( Expiration Date ) CoQ <br /> Date dAA.J <br /> L Y �Con Otoo <br /> Signature: Q /W G �!/+ � Title.. <br /> Printed name: R010GRT /= . V/ L�Cit4 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penally 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 Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. <br /> V I 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 issued- My workers' compensation insurance <br /> .. _.._.. carrier and policy numbers are: <br /> Carrier: &A,6 11(ZAAJ Policy Numbor: l')-T A/Pi l- ,f 000 <br /> I certify that in the performance of the work for which this permit is issued, I shan not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of Califomia,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 /> Expiration bate: _Signature: 7 <br /> Printed Name: b crCN /c,ii <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 /> ($100,000.1, IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ' /U-TH�ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, A�f�'�/1 -E /�C.1/1.JI (signature o10b7 licensed authorizod reprosentative), <br /> hereby authorize(print name) <br /> to sign this San Jeaquln County Well Permit Application on my behalf. I understand this authorization is valid for <br /> one(t)year and is limited to the work plan dated on the front page of this application. <br /> 5-29-02 1 W <br /> Lilo 29A2.nol <br /> 6/22,1 04 <br /> 04/2:1/2007 )ION 18:00 ITS/RS NO 77981 UOU2 <br />