Laserfiche WebLink
Signat <br />Printed narrr6; t c-t-t-01-0.1-•<1 A • <br />Titiscri;-7er 6 /6 M4( <br />sIw C y L-47-77— <br />License 4: .-S7S- <br />Date: C> F- le -0 Contractor: <br />Expiration Data: <br />rz_ C6 <br />C:)/-3 O 3 <br />c_.4-fr-r 71-- , <br />(C-57 licensed authorized representative), hereby <br />74— trei fil e),‘"- 67.0 Li /-O 00 1-4.. 1).-.0 r/rtv 1 00 oi• I authori <br />kteN,Lt1 C <br />JAsi 41W3at Sep. 18 2001 09:58RM P2 FRX NO. : 19166388613 <br />San Joaw:iip CiouiiW Environmental Health Services, Unit IV Well Permit ApPlcatk;n:Supplement <br />JOB ADDRBSS:i. '4%66 A ;c=1/51 C 44- , PERMIT SR#: 019; <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 />WORKERS' COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (CHECK ALL THAT APPLY) <br />I hay. 0 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 />Xhave tind will maintain workers' crimponsation insurance, as required by Section 3700 of the Labor Code. <br />for the performance of tho work for .Thich this permit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br />Ca trier: eit•/4- ritrall-k43 Policy Number: '2 2- It') v / 6 17 2. 7‘-it <br />I certify that In the performance of tho 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: 1,) SignatUre 62 . <br />Printed Name-- /t - <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 PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />to sign thls San Joaquin County Well Permit Application 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 page of this application. <br />5-17-20013i MI <br />NOMA 1-11IA EEOESSP606 VS:LO oon/szieT