Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 531 W.Yosemite Avenue PERMIT SR # <br /> Project site address: 420 W.Yosemite Avenue <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 licenis in full force and effect. <br /> License #: Exp Date: �T��// ' <br /> Date: Contractor: L�" <br /> Signature: / Title: 92740/Z!' <br /> Print Name: fUhP1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 /> 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 c trier and policy numbers are: <br /> Carrier: Policy Number^"C6VO/6�//� -t <br /> r <br /> I certify that in the performance of the work for which this permit is issued, 1 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 /> Exp. Date6/ Z Signature: ==EMS- <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 $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. 1 <br /> N OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> L < - (signature of C-57 licensed authorized representative), I <br /> hereby authorize (print name) to sign this San Joaquin County Well & Boring Permit <br /> i <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 /> EHD 29-01 05/09112 WELL PERMIT APP( <br /> 1 <br /> 4 <br />