Laserfiche WebLink
�.r <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 139 South Center St Stockton CA PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: ��� Exp Date: <br /> Date: 2� Contractor:Cl i V1 I I I�'Gl L ' <br /> Signature: RDC Title: �7 ��-E -1 V kqS �GL✓t� <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> 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 /> have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensa/�tion insurance carrier and policy numbers are: <br /> Carrier:_AI A,Skms-Nat p v,A-( I 091WAtli Volicy Number: I W WS�O 3 <br /> GO. <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to the workers' compensation law of California, <br /> and agree that if I should become subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those visio s. <br /> Exp. Date: 12( I Signature: <br /> Print Name: Fhkti CJncr�wy"q, <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> I' D1�UT ORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> y (signature of C-57 licensed authorized representative), <br /> hereby authorize print name) I Old �, to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 07125/10 <br /> WELL PERMIT APP <br />