Laserfiche WebLink
San Joaquin County Environmel ntal Health Department <br />WELL & BORING PERMIT APPlfICATION SUPPLEMENTAL <br />JOB ADDRESS: I\J Crr,1/4;c. Skfr, Miay-an. \-,„ CA (K1241. PERMIT SR <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: idly tk <br />License St: (6 CILCS- Expiration Date. 6 /34r-4 \-N <br />Title: <br /> <br />coac <br /> <br />WORKERS' C(*.iMPENSATIOil DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />D <br />permit is issued. <br />provided for by Section 3700 of the Labor Code, fdr the performance of the work for which this <br />I have and will maintain a certificate of consent to Self-insure for workers compensation, as <br />I have and will maintain workers' compensation in urance, as required by Section 3700 of the <br />'.IEL Labor Code, for the performance of the work for cv ich this permit is issued. My workers' <br />compensation insurance carrier and policy numt,es are: <br />, Carrier: e Ati b Policy*: Exp. Date: <br />I <br />I certify that in the performance of the work for which this perrnit is issued, I shall not employ any person in <br />any manner so as to become subject to the workers' coMpensation isiw of California, and agree that If I <br />should become subject to workers' compensation provisio s of Section 3700 of the Labor Code, I shall <br />forthath comk1 provisions. <br />Signature: <br />Print Name: Date: <br />0 <br />Signature: <br />Print Name: c <br />WARNING: FAILURE TO SECURE WORKERS' COMP SA <br />SUBJECT AN EMPLOYER TO CRIMINAL PEN <br />ADDITION TO THE COST OF COMPENSATION, IN <br />AS PROVIDED FOR IN SECTION 3706 OF THE LAB <br />N COVERAGE IS UNLAWFUL, AND SHALL <br />IES AND CIVIL FINES UP TO $1011,000, IN <br />EREST, ATTORNEY'S FEES, AND DAMAGES <br />R CODE <br />AUTHORIZATION FOR OTHER THAN C-57 S NING PERMIT APPLICATION <br />6\VIY8\96.L*Da.c., , hereby authnrize <br />to sign Otis San Joaquin :County Well & Boring P ml <br />authorization Is valid for Ofb• year and Is Ilridt <br />t)t af <br />Application on my be If. I understand that' <br />n dated on the Tract page of this application. <br />Sks Mfbpstion Well Permit Appltalion EHD 23-01 6-23-2015