Laserfiche WebLink
Sa•i Joaquin County Environmental Health Department <br /> WELL S BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 5 C�- <br /> JOB ADDRESS: C10 { 24� r ' ' T 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 BLsiness and Professions Code and my license is in full force and effect. <br /> Contractor Name: % - M -- v�,� <br /> Expiration Date: A0�,, ■ � J1> <br /> License#: } <br /> Title: • --- <br /> Signature: <br /> � <br /> Print Na e: b �• S,(� Dater -- <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: Policy#:q2)20&A .--_ Exp. Date: <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 com I yth those provisions. <br /> I <br /> Signature: <br /> Print Nam . <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 'N SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, �.C�,f hereby authorizeCw�+ �e^�,N�,..a <br /> N a l ansa0 Ful oni.,f Nepn TRn'v nn, ^ <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 rk a on the front page of this application. <br /> EHD 29-018-1-2017 Site Mitigation Well/Boring Permit Application <br />