Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> [JOB ADDRESS: G C (1,,J L c-E R� _7_C�Ac PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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#: C�� 1?o . f Exp Date: 0-'�O-Jq <br /> Date: �� y Contractor: <br /> J <br /> Signat Title: CEO <br /> Print Name:_ wPcn <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 <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: WPc�(o j�cxaf�a(11�. ,�myr�n Policy Number:•\x,�,41J\-J <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 provisions. <br /> Exp. Date: "A, 20\� Signature: <br /> Print Name: -tures �,Jcu4A <br /> v <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 /> AlJ- ORI ON,FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> w c �.I'1 (signature of C-57 licensed authorized representative), <br /> herebyauthorize '`'"' <br /> au (print name) I y , to sign this San Joaquin County Well 8 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 /> CHD 2301 05.'05112 <br /> WELL PERMIT APP <br />