Laserfiche WebLink
.. � ? 0 <br /> San Joaquin County Environmental Health I.iapa tment <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: G L Ori f'I=f:A'1T SR <br /> # <br /> LICENSED CONTRACTORS DECLVRATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 0 'cxnmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Iil:q.,rs1: is in full force and effect. <br /> License #: 5,�c Exp Date: <br /> Date: <br /> Contractor: <br /> Signature: % Title: = -;t,- t <br /> G, /l , <br /> Print Name: -- <br /> U <br /> WORKERS' COMPENSATION DECLAI::ATION <br /> I hereby affirm under penalty of perjury one of the following declaraticnE: l 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 pF!rfcrr-Iance of the work for which this <br /> permit is issued. <br /> have and will maintain workers' compensation insurance. as •equired by Section 3700 of the <br /> Labor Code; for the performance of the work for which `iia Dermit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: `> lll� �C� Policy Nu nber: <br /> I certify that in the performance of the work for w-iich this p1: rrlit 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 provision:-,. <br /> L Pr��� r Imo. g " ,;-;: . <br /> Exp. Date' S , i nature: :. �• <br /> Print Name ,=`'—} • G <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAVIFU_, i%ND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IIJ ADDITION "O '-H[i COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 --'H:i LABOR CODE. <br /> AUTHO N'FOOTHER THAN C-5'7 SIGNINI: PERMIT APPLICATION <br /> (signature of C-5'� licensed authorized representative), <br /> hb t�orize Int name) Tim Cuellar to sign this San •Joaquin County Well & Boring Permit <br /> Application on my behalf. l understand this authorization is valid fur Drle year and is limited to the work <br /> plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> EHD 29-01 0712&10 <br />