Laserfiche WebLink
EHD 29-01 07/20/10 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> [JOB ADDRESS: d IO O� S v(*G/aA 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 Business and/Professions Code and my license is in full force and/effect. <br /> `7 <br /> License#: Y516r Exp Date: <br /> Date: 7 /Z Contractor:Grp <br /> Signature: Title: Of ?cs7(Oi�f ✓��h <br /> i <br /> Print Name:_ <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) I <br /> XI 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: /yxiwe' (--- Policy Number: i'f1�WOIOI71//O0 <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, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisio <br /> Exp. Date: 1 //y Slgnature: � <br /> Print Name:�/�j <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> �'M CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> �+L-.�htTOR7YI'_+V'sfFt"$S'.dr�DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. (signature of C-57 licensed authorized representative), <br /> hereby authorize(print nam ) ,to <br /> sign this San Joaquin County Well& Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this'application. <br /> EHO 29A1 07aW10 WELL PERMITAPP <br />