Laserfiche WebLink
o 0 <br />I <br />$► San Joaquin County Environmental Health Department <br />.� WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />r <br />JOB ADDRESS: �l Ala V,/ 2ri r? ). Stoc �-to,1 �%� PERMIT SR # _ <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 #: 705927 <br />Date: 2/18/2015 <br />Exp Date: 5/31/15 <br />Contractor: Vironex Technical Services, LLC <br />Signature: Title: Operations Manager <br />Print Name: Robert M <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 issued. <br />X 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: ACE American Insurance Company Policy Number: RWC C48119384 <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' c mpensation provisions of Section 3700 of <br />the Labor Code, I shall forthwith comply with those pr ii ions. n <br />Exp. Date: 10/01/15 Signature: <br />Print Name: 10 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER 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 />= "-THORIZATION"POR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />1, (signature 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. 1 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 />EH0 29-01 05/09/12 WELL PERMIT APP <br />