Laserfiche WebLink
I• <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2^)a3 J z°Jcs <;J. t;,-.,;-,, „ )4,Jt PERMIT SR# <br /> cn� c�-�u �rro.i..o1i°�.J �«.c1J (Jli c�,���cl p�:...�: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 is in full force and effect. <br /> -License#: C17 Y911-667� Exp Date: ��- <br /> Date: Contractor. <br /> Signature: 9Title: COLd2-crPrTL�ir- /�O/sari.00� <br /> Print Name: 6I-0,07e'e- <br /> `f b l�D1AQ load i <br /> 1114at-by14z. C/A WORKERS' COMPENSATION DECLARATION <br /> SOD <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) aT <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 thts�..... <br /> permit Is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of tfi <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' <br /> compensation insuran_c/e�carrier and policy numbers are: - <br /> Carrier:( 00' R Policy Number: 04/ea/©10 Yt'10el- <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 Californipl <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 provisio . a , <br /> Exp. Date:_ .5�.3�/� Signature: ? 171 s <br /> Print Name:_ <br /> eCs, <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER.TO, <br /> CRMNAL PENALTIES AND CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEI"S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. _•_ <br /> LI RI ION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> -- �r;y <br /> 1. (signature of C-57 licensed authorized representatiV4E) <br /> hereby authorize(print name) Ski— cow,/Sk kc , to sign this San Joaquin County Well &Boring P69f <br /> Application on my behalf. I understand this authorization is valid for one year and Is limited to the wprk <br /> V <br /> plan dated on the front page of this application. <br /> HHD 2"1 05A=12 WELL FE�1C8�APP <br />