Laserfiche WebLink
JOB ADDRESS: 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 Division <br /> 3 of the Business//and Professions Code) and my license is in full force and effect. <br /> License -�=-� Expiration Date: I O -CO <br /> Date: Contractor: A&E <br /> Signature: /��� Title: +a 4 62 <br /> Printed name: I� l^I Gy1 41 i11'17ao <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> _I 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 /> -'X 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 <br /> {numbers are: <br /> Carrier: F"V1J Policy Number: t )_7 7 —93 2 <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 /> Date: ? - 2 -UC) Signature: (�j <br /> Printed Name: rlah /V`111./"GV, <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. <br /> 1, (C-57 license holder), hereby <br /> authorize of (consulting),to sign this San <br /> Joaquin County Well Permit Application on my behalf. I understand this authorization is valid for one(1)year <br /> and is limited to the work plan dated on the front page of this application. <br />