Laserfiche WebLink
Signature of C5U <br />San Jo _Ain County Environmental Health Dep, .ient <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS: 2600 W. Yosemite Ave. PERMIT WP #: <br />LICENSED CONTRACTORS DECLARATION <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 />Contractor Name: 4u0fl 1\ <br />Expirati n Dat c)/C' <br />Title: <br /> Date: <br />License #: <br />Signature: <br />Print Name: <br />WORKERS' COMP SATION 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 />1:1 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 />com-piensat on i urance c rrier and policy numbers are: — <br />Carrier: )L t n() Policy #: -)(..)(:).74--,/ Exp. Date: it) ' <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 so 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 />T. hwith comply with t ose provisions. <br />Signature: LI) <br />- <br />Print Name: <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 /> <br />44UTHORI TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />:‘1 .,(11 1 17 II , hereby authorize <br />tt. Till/ itiq N o of C-57 Licensed therao opresontativo Pri Name o o <br />ne:wizeaei <br /> <br />to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand fis <br />authorization is valid for one year nd is limite to the wo k plan datT:1 on the front page of this application. <br />EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application