Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION 1,CD) <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 at. <br /> t-1 . ;,an �C) I <br /> License#. laor-i - 0 <br /> Exp Date: <br /> Date: . I <br /> Contractor. <br /> -AJ n a-1 <br /> Signature: Title: <br /> Print Name: k-Sr-A/-x=-,Y- I R V1 <br /> WORKER'S COMPENSA N 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 camel and policy numbers are: <br /> Carrier: Policy 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,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 provisi ns. <br /> Exp.Date: Signature, <br /> Print Name: <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 DAMAGES AS PROVIDED FOR IN SECTIIO®N 3706 OF THE LABOR CODE, <br /> R OTHERTH�AN C-t67 IGNING PERMIT APPLICATION <br /> S ( <br /> (31 "a ulo of <br /> f g <br /> C-67 licensed authorized representative), <br /> hereby authorizeWarne} f--Z,1-1 <br /> sign <br /> is San JOB(print <br /> county <br /> Well P rmit Application <br /> . n on to <br /> this quin un e A behalf. I understand this authorization is valid <br /> for one year and Is limited to the work plan dated on the front page of this application. <br /> EMD29-0111M7 <br /> WELL PERMfT APP <br /> L <br />