Laserfiche WebLink
w <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 /> Contractor Name: ''\\ <br /> License#: U Expiratio ate:Va <br /> Signature: Title: r(/ <br /> Print Name: 1� j� Date: <br /> WORKERS' COMPENSATIO 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 /> La or Code, for the erformance of the work for which this permit is issued. My workers' <br /> c m�ensation ins ahce carrier and policy numbers are: I <br /> Carrier: J-rAPolicy#: ( I��/ Exp. Date:JQ h <br /> 1 certify that in the performance of the ow rk`'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 worke ' compensation provisions of Section 3700 of the Labor Code, I shall <br /> h2comply with those provisions. <br /> Signatur <br /> Print Name: <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 /> hereby authorize D"till'Ir Sid C liC�- <br /> Name of C- tens ut z epresen the —r �F'nt .1 tU prized gent <br /> to sign this San Joaquin,County) ell & Boring Pejrmit,Cpplication on my behalf:fi"understand this <br /> authorization is valid for one ear � is li Zld tath ' plan dated op the front page of this application. <br /> a rtepressave - <br /> EHD 29-018-1-2017 Site Mitigation Well/Boring Permit Application <br />