Laserfiche WebLink
San Joaquin County Environmental Health Department <br />@FELL azo BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: �flV C. IrV,6 . Gr✓lr��f? Lam; FCI?Ei4i a SI? <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 #: i� % i` � -fes Exp Gate. ��= / /i�� <br />� 7 r <br />Date: c/_1 _ Contractor: <br />i <br />Signature: �i�.r:�L Title: <br />Print Dame; <br />WORKERS` 1:61' PENSA C iON DECLARATION <br />ION <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 />1� permit is issued. <br />r� I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />1 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: 4h1//1_/ Folicy Number: /i %a_ynl�J <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 manner 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. <br />Epp. ®ate: Signature: <br />Print Name: <br />W—^R%1ING: FAILURE TO SECURE VVORKERS' C0110PENSATIOI. COVERAGE IS VNLAwF13L, AND SHALL SUSiEC T AN EWPLOTER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />ErAY c�ATI > <br />OR OTHER T HAA C-57 SfGKI IG PERMIT APPLICATION <br />1Signature of C-57 licensed authorized representative), <br />hereby authorize (print name) , 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 />EHD 29-01 05W/12 WELL PERMIT APP <br />