Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: U6?j CA64 PERMIT SR <br /> LICENSED CONTRACTORS DECLARATION (LCD) <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 /> License #: Z ' u 1 Exp Date: lZh, 1 12-,N <br /> Date: "J Z I Contractor: ��1� 1,� > ��G> t e-Lk) ` C.L I <br /> Signature: � - �) /�{ /✓�'�; �/— Title: C`«Y-.-u— C,"i,-Ci C+C�l� <br /> Print Name: 1Jt�rl �'y�IIIA l k) ti ( �1 <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: I1 t i ll;kLe f-kak CaSuid-tq , D,5, Policy Number: 2-2 W j: V L J4 gLe C19 <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to 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 provisions. <br /> _ <br /> Exp. Date: l�- I / 1 Signature: <br /> Print Name: <br /> WARNING' FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000: IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) ' 7-rrrioyt, a�,,, to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understan 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 25-01 OV26110 ,VE-L PERMIT APP <br />