Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL I-`- <br /> JOB ADDRESS: 531 'vv.Yosemite Avenue PERMIT SR# _ <br /> Project site address: 420 W.Yosemite Avenue <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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 /> srcn,yErrF Exp Date: <br /> License / <br /> Date: / / Contractor: <br /> Signature: / Title: ��=/'Ca' IO/> � /77��r>�„�,�- A. <br /> Print Name: � /i <br /> WORKERS' COMPENSATION DECLARATION - <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> r�1 � <br /> It 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 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 insurance carrier and policy numbers are: <br /> Carrier: CCt,)O/O OO Policy Number: �CGUG/O f <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 provisio ; <br /> Exp. Date: ( 3/ 1 I Signature: , SIGN <br /> Print Name:__ � /'l� //l'r.1'7(f- - <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. <br /> RIZAT��N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I Gil SIGN HERE (signature of C-57 licensed authorized representative), F <br /> hereby authorize (print name) , 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 /> i <br /> -a oc t2 <br /> 'WELL PERMITAPP <br /> E <br /> +f <br /> t <br />