Laserfiche WebLink
San Joaquin County Environme ntal Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: %V S\ C 0\0 1\UO PERMIT SR #1 <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: Lk \ _k _;c W_.0 )C CN)A( <br />License #: Ch-i)c-c\ Expiration Date: <br />Title: \-)I( Signature: <br />Print Name: <br /> <br />Afx v-k Date. an \2:1' )..en <br /> <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 />0 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 />0' 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: , \ \CA Policy #: ( Exp. Date:U.-A <br />certify that in the performance of the work 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 workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions. <br />Signature: <br />Print Name: <br /> <br />kJ(' '7 4 <br /> <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. I \ITEREST. ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LAI3OR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />,hereby authorize \I, <br />Print Name of Authorq Agent <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this <br />authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br />EHD 29-01 6-23-2015 Site Mitigation Well Permit Application