Laserfiche WebLink
San Joaquin County Environ► 'Ital Health Department Unit IV Well Pen�lpplicatiaa Supplemental <br /> ' JOB ADDRESS: � 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 e <br /> License# tt a 0 ci 0 4-- E Date: ' <br /> Date: Contractor: ZYl V( <br /> Signature: ,^ <br /> Title: Y 1"y---• <br /> Print Name: 'J(-�•- v� <br /> WORKER'S COMPENSA N DECLARATION <br /> 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 per6omnance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers'compensation insurance, as required <br /> Labor Code, for the performance of the work for which this q by Section rker of the <br /> compensation insurance ramie and policy numbers are: permit is issued. My workers* <br /> Carver-a� Policy Number. ( l ''V V% <br /> r . l V <br /> person in any manner so as to become subject to the worker,'compensation law of CI certify that in the performance of the work for which this permit is issued, I shall not ealifornia, and <br /> mploy any <br /> agree that if 1 should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those pro . ' ns. <br /> Exp. Date: Signature: Ciul <br /> Print Name: 4-- V 1 L <br /> WARNING:FAILURE TO SECURE WORKERS'coMpFNSAmON COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRWNAL PENALTIES AND CML FINES UP TO$100,000,W ADDMON TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DA�fAt3ES AS PROVIDED FOR IN SECTION 3704 OF THE LABOR CODE <br /> O <br /> �ROTHEFR THAN C-57 SIGNING PERMIT APPUCATION <br /> I, (signature of C-67 licensed authorized representative), <br /> hereby.authorize(print name) -_ road CL b to 0 75L <br /> to <br /> sign this San Joaquin county Well Permit Applicatlon-on my behalf. I understand this authorization is valid <br /> for one year and is aim bed to the work plan dated On the front page of this application. <br /> eia.�a21r11 <br /> EH02U1 tU5A7 <br /> WELL PERMIT APP <br />