Laserfiche WebLink
0 0 <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOBADDRESS: A2q PERMIT SR#: G6 �Oa�b <br /> njz��W) C1+ c Sao <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Dlvlslon <br /> 3 of the Business and Professions Code and my license Is In full force and effect. <br /> License#: _70G5606 Expiration Date. 5 jai IOs <br /> Date: 17-(2.1 I04 Contractor: Tec-%- Paritem cmfa,,.id t Mi,C-• <br /> Signature: 5!4h2! = Title: C-Fo <br /> Printed name- LeIF F JnnsSo r`t <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-Insura 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 /> 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 issued. My workers'compensation insurance <br /> carrier and policy numbers are: <br /> Carrier: % wale -Pt lwO Policy Number: I G OG 03 ^200!� <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, 1 shall <br /> forthwith comply with those provisions. <br /> Expiration Date: - —Signature: <br /> Printed Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CNIL 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- <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature ofC-5711censed authorized representative), <br /> hereby authorize print nari "Bc, -H} 46*4w <br /> to sign this San Joaquin County Well Permit Application on my behalf, 1 understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> 8-29.021 MI <br /> END 29-02-001 <br /> 622104 <br />