Laserfiche WebLink
--r wr<n <br /> 916-313-339 <br /> Oct 03 2007 11 .49RM Raro�e Ep. 2 <br /> nvironmental , Inc (775) �I -7240 <br /> . P- 2 <br /> 1 <br /> San Joaquin County Environmental Health Department Urtit IV Well Permit apppcatlon Supplement <br /> JOB ADDRESS: 2Z'2 �. lw �3�R v s ocltrd H PERMIT SR#: <br /> LICENSED CONTRACTORS DECLARA'T'ION (LCD) <br /> I hereby affirm that I am tioensed under the provisions of Chapter 9{commencing with section 7000)of Oivision <br /> 3 of the Business and Professions Code and my license is in full force and effect. <br /> License#: C57 933S701 Expiration Date: 1-2.It 3 I �$ <br /> Date: 10-1-07 _Contractor. e (nef ���o ✓Cc /7 z,,,> r y,, <br /> Signature ���iro <br /> Tide:_stn:oy [7Cdlo4i Sf <br /> Printed name: ew? <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-lnsurs for workers'compensation,as provided for <br /> j by Section 3700 of the Labor Code,for the performance of the work forwhich this permit Is issued. <br /> 4 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'eompansaHon insurance <br /> carrier and policy numbers are: <br /> Carder:.5+� �74-1 c1 Policy Number. 5111-OQDO 417- D Le <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 Califomla, and agree that if I <br /> sheuld become subject to the workers'compensation provisions of Section 3 00 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date: '311 G Signature. <br /> Printed Name. <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATtON COVERAGE IS UNLAVVFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES ANO GIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> (Et00A�•),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR 1N SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature*fC-57 licensed authorized representative), <br /> hereby authorize(print name)_ :TD 5 H R M E <br /> to sign this San Joaquin County Well Permit Appilcatlon on my behalf. I understand this authortzation Is valid for <br /> one 11)year and is limited to the work plan dated on the front page of this application. <br /> B-29-021 MI <br /> EHD 29-02-001 <br /> 6=4 <br />