Laserfiche WebLink
L <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL, <br /> JOB ADDRESS: 2 103 d 299.1 (,.J r' 14 ..0 r;V( <br /> / PERMIT SR# <br /> (JL( <br /> i 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#: G�7 - Exp Date: <br /> Date: Z Contractor: �'�-� <br /> Signature: Title: <br /> Print Name: <br /> q jb 1' bwR <br /> Mdi}.ywz c1A WORKERS' COMPENSATION DECLARATION s <br /> BOD <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) cf ; <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' r <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: � Policy Number: 119/61Ld1V Ywol <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> P 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 provislori as <br /> Exp. Date: Signature: <br /> Signature: <br /> _T <br /> Print Name <br /> li <br /> D SHALL SUBJECT <br /> WARNING:CFAILURE TO SECURE RIMINAL PENALTIES AND CIVIL FINES UP TO$100,OQOAIN ADDITION TOUTHE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU R_ I ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION rly <br /> (signature of C-57 licensed authorized representati-i-- <br /> hereby authorize(print name) to sign this San Joaquin County Well &Boring Pe94 <br /> Application on my behalf. 1 understand this authorization is valid for one year and is limited to the wwk• <br /> plan dated on the front page of this application. <br /> ' 4VEL1:tsEf�T'AT7iPP ' <br /> C-HP 29-O7�5`OSJ12 r.::i•' <br />