Laserfiche WebLink
© 6^01 9166385511 CASCADEDRILLING <br />PAGE --03/.04 <br />san Joaquin County Environmental Health Department Unit IV Well Permit Apptlo on Supp(ament <br />JOB ADDRESS: � A <br />r-- PERMIT SIS#, DDq!Ut7,- � RVO�l P) <br />LICENSED CONTRACTORS DECLARATION (,LC -D) <br />I hereby affirm that I am licensed under the provisions of Chapter S (commencing with Sectlon 700) of Division <br />a of the Business and professions Code and my Iloenre is In full form and effect. <br />License*: %r%J�iii Expiration Date:, d� — <br />^ A <br />Date, <br />Signature: <br />Printed ns <br />--I-, Z-� r e/ <br />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br />1 have and will maintain a certificate of consent to self -insure far workers' compensation, as provided for <br />by Section 3700 of the Labor Cotte, for the performance of the work for which this permit is issued. <br />I have and will maintain workers' componsstion 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 nnumbem caro: <br />CsrriEr;/f�`Ift /�•�fO�G policy Number: <br />I cerrafy 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 CalPf mia, and agree that if I <br />should became subject to the workers' compensatlon provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with t ose provisions, / <br />Expiration data: -� Dja Signature:"'�`�/ <br />Printed Name: <br />WARNING; FAILURE TO SECURE WORKSRS' COMPENSATION COVERAGE Is UNLAWFUL, AND SHALL SUBJECT <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br />($100,000.), IN ADDITION TO'(HR COST OF COMPENSATION, INTEFI[ItOTI ATTORNEYS FEES, AND DAMAnES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUT/�URIZAT�N FO7/1 <br />R R THAN C-57 SIGNING PERMIT APPLICATION <br />of"7 Iloansed authorized repronen,t4YA), <br />hereby authorize (print <br />to sign this San Joaquin County W611 Permit Appiicatlon on my behalf. I understand this authorization is valid for <br />one (1) year and is limited to the work plan dated on the front papa of this nppllcaitlon. <br />5-29.02 f MI <br />parr) 19.07-001 <br />bR�lOa <br />