Laserfiche WebLink
Iq <br /> San Joaquin County Environme ital Health Department <br /> WELL & BORING PERMIT APPLI ATION SUPPLEMENTAL <br /> Wd7'�' 1)v 4 7,Z I <br /> PERMIT SR# <br /> JOB ADDRESS: ��/`�' / ' ' <br /> o � z <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter. 9 (commencing with Section 7000) of I <br /> Division 3 of the California Business and Professions Cod,, and.my license is in full force and effect. <br /> License#: Exp c_�c�� - Exp Date: .j <br /> Date: > } \XIC 11. 1r ` 01, Contractor: <br /> Signature: •- - ��� Title: i <br /> Print Name.-- <br /> WORKERS' <br /> ame: WORKERS' COMPENSATIC N DECLARATION <br /> I hereby affirm under penalty of perjury one of the following I declarations: (check one) <br /> i <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 /> J� I have and will maintain workers' compensation nsurance, as required by Section 3700 of the <br /> Labor Code; for the performance of the work or which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are. <br /> �a ( I)olicy Number: <br /> I certify that in the performance of the work for wt ich this permit is issued, I shall not employ any <br /> person in any manner so as to become subject I:) the workers' compensation law of California; <br /> and agree that if I should become subject to workt!rs' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 1 _ Signature:—=:: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAC E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100.000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SE,:TION 3706 OF THE LABOR CODE, <br /> AUTHORIZAT[ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signatu •e of C-57 licensed authorized representative), <br /> ' !d'.2nceG Gec[mm�xru Hca! <br /> hereby authorize(print name) FPPresemaoves to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> 1 <br /> F.H•D23.05 0%/2V 1U WEIAPLWAITAPP <br /> I <br />