Laserfiche WebLink
San Joaquin County Environm ental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 34'00 Newton Road <br /> PERMIT SR# <br /> LICENSED CONTRACTOR` DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions o Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Califomia Business and Professions Cod= and my license Is in full force and effect. <br /> License#: C_' T� Exp Date: iMu 2.(112 <br /> Date: Contractor:_�lll ''.1� 11 �� X S 11( � ,► Y 11f <br /> Signature: Title.- <br /> Print <br /> itle:Print Name: <br /> WORKERS' COMPENSATICN DECLARATION <br /> I hereby affirm under penalty of penury one of the followinc 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 i isurance, 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 number: are <br /> Carrier: , 0AP I 11 \CI P Aicy Number: I <br /> I certify that in the performance of the work for whi ;h this permit Is issued. I shall not employ any <br /> person in any manner so as to become subject tc 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 )-rovisions. <br /> Exp. Date: j _ , Signature: <br /> Print Name:_ t fib. <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SU6JECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100.000. IN A EDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECT ON 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 :IGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to sign tt is 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 01/13111 <br /> ASL:PFRMiT PPP <br />