Laserfiche WebLink
Dec 11 12 10:52a R 8 p.2 <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �� ?23 7II��1���/ ���"I PERMIT SR It <br /> i <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 its in full force and effect- <br /> License t G� �`�`"[C'7 5 Exp Date: l_ 114 <br /> Date: Contractor: <Dc 1 -,.J(_i <br /> Signature: <br /> �� <br /> Print )Name:cJl 1,�A Get(r i�i <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 /> 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 ins a ce carrier and policy numbers are: <br /> A�p J7,' Ca±xQe.SA-fir <br /> Cai ,%<,rYLJeAr,>_ PoticyNumber. -��-G' <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 compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with se P. visI <br /> Expo Date: Signature: <br /> Print Name:( <br /> WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO $100,D00,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 /> UTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l (signature of G57 licensed authorized representative), <br /> hereby authorize(print name) ,�ir34 u h�i ,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 /> EHD29-M 05M9f12 WELL PER IT APP <br />