Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 540 North Hunter Street. Stockton, California 95202 PERMIT WP #: <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: <br />---, <br />License #: 90,g9C), j r Expiration Date: \\ /30 /018 <br />Signature: °141/ <br />Title. C,E.C) <br />Print Name* I or, r \ NJO yr ( \ Date: <br />WORKERS' COMPENSATION 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 />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: We,s\(/) It'ISO (Oa, ei:), Policy #: ,-,),,-) Exp. Date: ')II)A01 <br />I 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/ Name/ 7 -6 5.(\ i\JO)),icr r l <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, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, "Tdo..iN j\ik,u -f (,f-\ ,:ciele,Lect, 0,-;,,,,, , hereby authorize <br />Name of C-Fticenfed Authorized Representative / T--- Pnnt Mann of ituthoneed 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 ,A limited to the work plan dated on the front page of this application. <br />Signature of C-57 Licenserl Authorized Representative <br />END 29-01 8-1-2017 <br /> Site Mitigation \Nell/Boring Permit Application