Laserfiche WebLink
r <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: 3940 N. TRACY BLVD. , TRACY, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: <br /> CII-680227 Exp Date: 11-30-2009 <br /> Date: 9-3-2008 Contractor: ADVANCED GEOENVIRONMENTAL, INC. <br /> VICE PRESIDENT <br /> Signature: Title: <br /> Print Name: ROBER E. MARTY <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> XXX <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by section 3700 of the labor Code, for the performance of the work for which this <br /> permit is issued. <br /> xxx I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> STATE COMPENSATION <br /> 1317474-2007 <br /> Carrier:INSURANCE FUND Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisio <br /> Exp. Date: 10-1-2008 Signature: <br /> W � ZZ4 <br /> ROBERTY E. MARTY <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 8/29/02/MI <br /> EHD 29-01 11/5/07 WELL PERMIT APP <br />