Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:2 c W. a owir sio 6 kiV,1) /52(%' PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <br />I 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 />f <br />Contractor Name <br />License #: <br /> <br />Expiration Date: 9 /3 / 1 9 <br /> <br />Signature: Bryan Cook <br />Daptalty 3102 by Bryan Cook <br />DO OnaBgan Cook orr011bou, 0113.1 k <br />Date 2018 06 PI 1602 36 -OM Title: Project Manager <br /> <br />Print Name: Kenneth B. Cook <br /> <br />Date: 5/31/18 <br /> <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 />I21 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: on file Policy #: Exp. Date: <br /> <br />I certify that in the performance of the work for which this permit is issued I shall not employ any person in <br />any manner so as to become subject to the workers' compensation law of California and agree that if I <br />should become subject to workers' compensation provisions of Section 3700 of the Labor Code I shall <br />forthwith comply with those provisions <br />Signature: Bryan Cook Digitally signed by Bryan Cook <br />DN. co =Bryan Cook. o=CDLP, on. email Axook@cascade on000,rr,D lik <br />Dale. 2018.06.01 160137 -071111' <br />Print Name: Kenneth B. Cook <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br />SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br />ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />Kenneth B. Cook <br />Name of C-57 Ucen Auth - and Representat <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br />Bryan Cook Oignally signed ny Bryan Cook <br />D. cnaBryan Coal, or-COlik, on, email=bcookaaascade enincom, caUS <br />Dale: 7018001160100 0700' <br />Signature of C-57 Licensed Authorized Representative <br />hereby authorize John Lane of Condor <br />Pent Name of Authonzed Agent <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application