Laserfiche WebLink
MAY-11-2005 15:00 FROM:ENPROB 5305892230 TO:12094683433 _ P.1 <br /> u.r •ate ww <br /> 05/11/2005 15:09y 205463 V FIFTH FLOOR * PAGE V02 VK <br /> San Joaquin County Environmental Hoaltb Department Unit IV Well Permit Application supplement <br /> 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 fUl force and effect. <br /> License m �``s 7-a 7-27 007 Expiration Date: O Y ` 10 - 20C (9 <br /> Date; S / —too S ontradw: if^/fRO6 <br /> Signature: Tate:�gNc✓ <br /> Printed name: �<✓/i//$ 0 TT <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm Under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br /> 1 have and will maintain a certificate of consent to self-Insure for workers'compensation,as provided for by <br /> Section 3700 of the labor Cade,for the performance of the work for which this permit is issued. <br /> N41 have and will maintain workers'compensation insurance,as required by Section 37DO of the Labor Co e, <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: SP - CamP _$�ic.Nt2 O'ONOPolicyNumber: �I 7 �'�� <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 baccime subject t0 the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. /h <br /> Date: 3-/ ' 20 S- Sigrzature: <br /> Printed Name: ✓e✓rIS D <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (5100,000,),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�2.vn>%3 <br /> 07-7- <br /> 1, (signature ofC-67lleonsad authorized repnzSentattve), <br /> herebyauthadf (print name) J¢y`�'7e"r�ycy(fes <br /> to sign this San Joaquin eaunty Won Permit Application on my behalf. 1 understand this authorization is valid for <br /> one(1)year and is limited tothe work plan dated on the front page of this application. ' <br /> 1-2"2 MI <br />