Laserfiche WebLink
Now, �..� <br /> • 7 <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 16M � PERMIT SR# <br /> LICENSED CONTRACTORS"LARATION LCD <br /> I hereby affirm that I am licensed udder the provisions of Chapter 9 (commencing with Section 7000)of <br /> Division 3 of the California Business sled Professions Code and my license is in full force and effect. <br /> License#: C1 7 � Exp Date: <br /> Date: Contractor: PG/ <br /> Signature: Title: - <br /> Print Name: <br /> COMPENSATION DECLARATION cl' <br /> I hereby affirm under petty Ltd si>V* me of the following declarations: (check one) <br /> _xl have and will rymoom d >rlltate of consent to self-insure for workers' compensation, as <br /> rovided for by Sedan*2M a tie Labor Code, for the,performance of the work for which this <br /> permit Is issued. <br /> I have and will Rtmltil]!, wisl1l aw compensation insurance, as required by Section 3700 of the <br /> Labor Code, for t~ vwfti ells of the work for which this permit is issued. My workers' <br /> compensation Insto on — wall policy numbers are: �/- <br /> Carrier:/?CVr,b Policy Number. le,,Tn�O10 <br /> I certify that in ft art the work for which this permit Is issued, I shall not employ any <br /> person in any .-WW%W to so VA become subject to the workers' compensation law of California, <br /> and agree that if I SUM I -P subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code,i OW drl141110w v ntply with those provisions. <br /> Exp.Date: 2//� Signature: <br /> Print Name: ���� td'c//�P� <br /> t WARNING:FAILURE TO SECUR=OPONOM1f'90110V SATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT AN EMPLOYER TO z <br /> CRIMINAL PENALTWS iM CWIL!i UP TO$1oa,000,iN ADDITION TO THE COST OF COMPENSATION,INTEREST,- :t, <br /> ATTORNEY'S FEES,AND OAUAGO+r MtOVIDED FOR IN SECTION 3T06 OF THE LABOR CODE. <br /> T! �ZA �FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. i understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> Y:hO 2A-01 0=9M2W WELL PERMIT APP <br />