Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _31igr �a5f mCt�it Sf, S�DCK�it, �� 95 *ERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1.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-s T $118 S69 Exp Date: ( [TIP mak' <br /> Date: .yx 1 Contractor: -41L 6cl6-LL "&1kQA11-r6 cGr <br /> Signature: % Title: <br /> Print Name: 0948 SL-46 6- <br /> WORKERS' <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:—,. Pol4dy`Number: <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: Signature: <br /> Print Name:__�)�,n I(' ('Ili - <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 DAr4AGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTH0�1,Z Tf-ER THAN C-57 SIGNING PERMIT APPLICATION <br /> l• �� (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) ft rdAibSWTV , to sign this San Joaquin County Well & 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 /> EHD 29-01 05109!12 - WELL PERMIT APP <br />