Laserfiche WebLink
�T San Joaquin County Environmental Health Department <br /> WELL& BORINC PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 7-Eleven#14117,2725 Country Club Blvd., Stockton PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter g (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#: �('S�3(r L1.to _ Exp gate: <br /> Date: QLD , I s't d-0 I L-( Contractor: <br /> Signature: 1���---- Title: Pr*1 I ( <br /> PrintName: �Cti`tt'tVl <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> I <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 whish this <br /> permit is issued. <br /> I <br /> I 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 /> compensation insura <br /> �nce carrier and policy numbers are: <br /> Carrier:L i Cn >/�M-er i ca4-Anw raspge Policy Number: V)C Q 3101 33,20:j <br /> I certify that in the performance of the work for which this permit is issued, I shat! 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 small forthwith comply%vith those prov�^ <br /> i <br /> �� S1 Q I —� <br /> Exp. Date:_, � _� Signature: <br /> Print Name: �G(-V:) �\ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN,EMPLOYER TO <br /> i CRIMINAL PENALTIES AND CIV;L FINES UP TO $ICC,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTQ ftErS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF TI4E LABOR CODE. 1 <br /> frill l BN R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) Stantec Gonsultinq , 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 /> I plan dated on the front page of this application. <br /> EHD 29 01 0509112 VVEU PERMIT APF <br />