Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: L1 '57 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 #: �_�`1 Lll Exp Date: Off -a <br /> Date: L, if 2, Contractor: rHK�_IcA C—QVI I f0WMCe_1 A L_ 5U,'ICE S <br /> Signature: Title: PtLE5 1 C)et.;T <br /> Print Name: C_7Gr� C-c- ► VL ' I-, <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: J7�f�' ��.^nL'. �2� F,10d Policy /?� <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 mannc 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. �Gpo� jC�j% J tc*,S <br /> Exp. Plate: i 7 f l:� Signature: ��^� � �� 1 `;-7 �/l6 I�� <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO $100,000, IN ADDMON 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 APPLICAT ION <br /> 19 (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) de 1c, FL,e:��c' , 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 /> EMD 2"1 05,09/12 WELL PERMIT APP <br />