Laserfiche WebLink
Itut11511 \tuie.15 <br />itudeff4 -01/ ex3-,1 cts-13 <br />aquin County Environmental Health Deparprnt Unit IV Well Permit Application Supplement <br />PERMIT SRL,_• °511511 <br />Cr5 <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 #: C -S -7 —717 510 Expiration Date: 131/10 <br />Date: C- 1-i- °V Contractor. Cg•--Stri,CDC v‘t <br />Signature: Title: 0 es . %My <br />Printed name: P:k "-?1\115tro <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-Insure for workers' 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 />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 pemiit is issued. My workers' compensation insurance <br />carrier and policy numbers are: <br /> <br />Carrier: VNGL.Skr..., (10.4-i0v\-0•-•( Policy Number: Tn-evis so 63 k <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 />Expiration Date: 5 - -0 Signature: <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 />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />AUTH IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I. (sigrsature ofC-67 licensed authorized representative), <br />hereby authorize (print name) V 0_-1-ce-- 6v-ir Mcie-1-2 /6-&? <br />to sign this 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 />8-29-02 / MI <br />JOB AD RESS: 100 5\--law -Read <br />5404,- Aie <br />Printed Name: <br />E1-11) 29-42-001 <br />6/22/04