Laserfiche WebLink
Ju 1. 31. 2012 11 :46AM No. 1037 P. 6/16 <br /> ` Iftod <br /> EMD 2"1 07110/10 VMLL PERMIT APP; <br /> } San Joaquin County Environmental Health Department # <br /> WELL BORING PERMIT APPLICATION SUPPLEMENTAL } <br /> J 0 B ADDRESS: �; t =r:. __;'(1t<;f t r k -.,6; .LM 1'i`tkl'-',i`,PEFMIT SR# -- - <br /> LICENSED CONTRACTORS DECLARATION (LCCA) <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 infull once and effect. <br /> license f: I'��� f Exp bate: � ! <br /> Date: Contraictor, <br /> Signature: <br /> F <br /> Print Dame: Cr U <br /> WORKiERS'COMPENSATIOM DECLARA ION € <br /> . i <br /> I hereby affinr under penalty of perjury one of the following declarations: (check one) <br /> I have and will maintain a certificate of consent to seif-msure for workers'compensation,as <br /> provided for by Section 3700 of the Labor Coda,for the performance of the work for which this <br /> i permit is issued. <br /> 1 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 la.Issued, My workers' <br /> I compensation insurance ca er and policy numbers are: <br /> I <br /> Carrier: �'� Policy Number. 19t1_6k1 (242 104 65 <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 1 should become subject to workers'compensatlon provisions of Section 3700 of the <br /> Labor Cod-,t shall forthwith comply with those provision <br /> (p. i]a,te: 112 Signature: <br /> Print Name: C/ t � <br /> WARNING:FAILURE To SECURE WORHERS'COMPF_p4SAn0N COVERAGE I$UNLAWFUL,ANTI SHALL.SU13JF-CY AN EMPLOYER TO <br /> CRIMINAL PrNA).TIES AND CIVIL FINES UP TO$100,000,IN/ADDITION TO Till?COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FE1=S,AND 13AIWACES AS PROWOED FOk IN SECTION 3708 OF THE LABOR COOL, <br /> T14 TIOW06k OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-67 licensed authorized representative), <br /> hereby authorize(prini,name) ,to <br /> sign this San Joaquin County Wen&Boring Permit Application on my behalf. I understand this autherization <br /> is valid for one year and is 11m1bed to the work plan darted on the front page of this applicatlon. <br /> »1A��t o77,19fto 1A�LL�t3i1A1rAP? <br /> F <br />