Laserfiche WebLink
L � <br /> I?I-ID 29-01 07120/10 <br /> WCI_I.PERMIT All <br /> ;an Joaquin County Environmental Health Department ~^ <br /> WELL & BORING PERMI"f,APPLICATION SUPPLEMENTAL <br /> JOf L4 cli, <br /> ADDRESS: 0 W, ice _ PERMIT SR# <br /> 'AD <br /> o,ek• M <br /> LICENSED CONTIWACTORS DECLARATION (LCD) <br /> I hereby affirm that I aryl licensed under the provisions of Chapter 9(commencing with Section 7000) of <br /> Division 3 of the lousiness and Professions Code and my license is in full force and effect. ` <br /> License 4: _ + �{p Exp Date: :b <br /> Date: Contractor: Gr (' <br /> Signature: . _ Title:��' �/ta' C / 1, O <br /> Print Name:- <br /> WORKERS' 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 /> -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: &671-W Policy Number: 152lC V/V/01/0VlIvi <br /> ,, <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 r <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Ae Signature: jj��10112!C <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 3706 OF THE LABOR CODE. } <br /> A OR TION OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> 1 <br /> hereby authorize(print name) ,,to , <br /> ,ign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization ` <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> WELL PERMIT APP <br /> r_•rio x�-ni o�nono , <br /> r <br /> f� <br /> f <br />