Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _ OSS_ _`J• c V\ AR wA _ PERMIT WP#: <br /> �$T CQK-rcn/ I C A <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 /> Contractor Name: >1 �0A U k)r1 - <br /> License MI Iii, Expiration Date: <br /> Signature: - Title: S 1dDR+ <br /> Print tfame. - Date <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 /> JW 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:� �f �j.:li Policy#: 9 W C i. 1__ Exp. Date: `II2J39L <br /> 1 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 /> with co ly-a4ttkt those provisions. <br /> Signature: <br /> Print Name: VA- SICIL 11 <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 <br /> PERMIT APPLICATION <br /> hereby authorize <br /> - N.m.az; u#��ce we'twno�.e a nnrnUtlw -- R1M N.me of AONodne Ap­l <br /> to sign this San Joaquin County Well& Boring Permit Application on my behalf. 1 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 /> „t.`-_•,. j_t :,t Site Mitigation Well/Boring Permit Applkat,o,i <br />