Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: - Il <br />PERMIT SR #: <br />LICENSED CONTRACTORS DECLARATION <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the qalifornia Bisiness and Professions Code and my license is in full force and effect. <br />Contractor Name: _ �.%. • ` ����_ <br />License #: r (j� Expirqfipn Date: <br />Signature: Title: � A <br />Print Name: tI � �� f) J -VA Date: 1) � <br />WORKERS' CQ.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 workers' compensation, as <br />® provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br />;permit is issued. <br />I hav, and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Q,w Laboe Code, for the performance of the work for which this permit is issued. My workers' <br />compensation insurance carrier and policy numbers are: <br />Carrier: Policy #: (� �Exp. Date: r' <br />I certify that in)he performanc oe�th� 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 law of California, and agree that if I <br />should become subj ct to workers' compensation provisionP of Section 3700 of the Labor Code, I shall <br />forthwith comply with tho provisions. <br />Signature: <br />Print Name: <br />WARNING: FAILURE TO SECURE WORKERS' CIDMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />HORIZATION FOR OTHER <br />WAM <br />to sign this San Joaquinoq <br />authorization is valid for once yar <br />r. <br />MON <br />, herebV authorize <br />II & 8 ring Permit Application on my behalf. I LiPiderstand this <br />lima mod,to the wok p)ap dated on the front pag, of this application. <br />EHD 29-016-23-2015 Site Mitigation well Permit Application <br />