WP0037929 - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: ,�jL,��j PERMIT SR #: LICENSED CONTRACTORS DECLARATION hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full fnrr,P ;;nri Af ort Contractor License #: Signature: Print NamE I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as 13 provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' 3EMZW7 and policy numbers aree:: Carrier: Policy #: �, V "' Exp. Date: 1 C) 1 1 certify that in the performance of the work for which..this permit is issued, I shall not employ any person in any manner so as to become subject to the workers compensation t w of California, and agree that if I should become subject to workers' compensation provisions of Sectio 3700 of the Labor Code, I shall rthwith comp with those provisions Signature: Print Name:IA� WARNING: FAILURE TO SECURE WORKERS' CONDENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION ,hereby authorize to sign this San Joaquin Coun4iWell & Boring Permit pplication on my half. I understand this authorization is valid for one year and is limit�d to the work plan dated on the front pa of this application. EHD 29-01 6-23-2015 Site Mitigation Well Permit Application