Laserfiche WebLink
I <br /> San Joaquin County Environmental Health Department Unit IV Well Permit Appp/lication Supplemental <br /> JOB ADDRESS: /d Y�TO at c!d`�tldE /l�yE PERMIT SR# �.V 05 <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 Business and Professions Code and my license Is in full force and effect. <br /> I <br /> License#: -4oCiS4$ Exp Date: S'31 �00P1 <br /> Date: R-40-0k Contractor: TEG- WoyNrnn Cal`�or nTi. <br /> Signature: 4 Title: RMo <br /> Print Name: IIe^W " r%- <br /> WORKER'S <br /> S WORKER'S 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 /> X 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 insurance carrier and policy numbers are; <br /> Carrier: Policy Number: I Gro ski- a t <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, and <br /> agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. 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 CIVIL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> (signature of C-67 licensed authorized representative), <br /> hereby uthorize(print name) ,tt*V41CA re&M— ►>.^r6t cwa�.s Iclf'�� ,to <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> 9129/021MI <br /> EH 2&0111/ 7 WELL PERMIT APP <br />