Laserfiche WebLink
JOB ADDRESS: 7/€16/-e- 41-14- <br /> <br />PERMIT SR#: 2-13 c8 <br /> <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 #: 7 26, / 7 Expiration Date: <br />Date: //7-2.g/4/ ,, Contractor: , / <br />/ PI 1 i <br />Signature: C ciiiiv a, 7( ii-'( r /4" Title: ,P eli,tle-7?-- <br />Printed name: EDWA-,--0 MrCee-feZL._ <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 />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 />Carrier:,.-.Cc4 .--e.- 6,--)"//9. Policy Number: /3/7 <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 become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Date: Signature: <br />Printed Name: <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 />PROVIDE KIR IN SECTION 3706 OF T4-I LABOR C E. <br />I, x ii /l( Vel( <br /> <br />, (C-57 license holder), hereby <br />authorize I k \ C \I C t \C ,( of 4 6 4_ (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 />,4•0 / / de <br />; (.7 <br />P/Pejef, 6;)CW-205.16,tr-e..tA