Laserfiche WebLink
San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 705 Carlton Avenue Stockton. CA 95203 PERMIT WP #7 1 <br />LICENSED CONTRACTORS DECLARATION <br />i hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000,i of <br />Division 3 of the California Business and Professions Code and my license is in full force and effect <br />Contractor Name: Environmental Control Associates (ECA) <br />License # 695970 Expiration Date 09/30/2018 <br />Signature: <br />Print Name: Tim Tyler MILA S‘nnertLIcir6el•ti.\ ol Date /1 LiA <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 issueo <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: 5- r Policy #: `..) Exp. Date: Kl'/ <br /> <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 sc 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 7/C <br />Print Name Tim Tyler <br />Title: Presiount <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 />IL041, hereby authorize /PA <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 />ENO 29.01 8-1-2017 Sou Mitigation Well/Poring Permit AppItcation