Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit ApplicationSupplement <br /> JOB ADDRESS: SPERMIT <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 Dusin%a and Professions ode andlicense Is in full force and effect. <br /> r4, / <br /> License#: C• 57 e Expiration Date: / l1 <br /> Dale: Z Contr r.�. <br /> Title: Q tooSignature: / <br /> Printed name: rS%O UAP1 <br /> WORKERS'CC+MPENSATION 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-Insure for worker:'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 /> A,I 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 /> Garrlcr: ✓Pabr�Q/i� Policy Number. <br /> I caNty 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 workefs'compeneabon 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 /> Expiration Date: g f/J Signature:Ili <br /> Printed Name: u <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 HUN12RED THOUSAND DOLLARS <br /> PD ,OR ISECTION 37®OFT E <br /> ADDITION TO THE COST <br /> OFCOMPENSATION, <br /> NSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED <br /> i =AUTIZA AN FOR OHTHAN C•57 SIGNING PERMIT APPLICATION <br /> (signature ofC47 licensed authorized representative), <br /> hereby authorize(printm <br /> nae) -Ro 6 e r"'C O n c,c\(NY) <br /> to sign this Ban Joaquin County Well Permit AppllGatlon on my behalf. I understand this nutnorization is valid for <br /> one(f)year and Is limited to the work plan dated on the Front Page of thin applloatlon. <br /> "s-02 f MI <br /> ERD 2942-001 <br /> &7244, <br /> TOTAL P. 18 <br />