Laserfiche WebLink
EHD 2"1 07/20/10 WELL PERMIT APP <br /> f San Joaquin County Environmental Health Department <br /> E WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: W Church Street and S San Jose St.Stockton.CA 95203 PERMIT SR# <br /> d <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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 /> License#: G'� �rt Exp Date: <br /> Date: _ L Contractor: t�dC �/• ��/�� <br /> Signature: Title: <br /> Print Name: 6! e/ !lam&1/lif� <br /> a <br /> S <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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 /> Xpermit is issued. I <br /> 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 /> I compensation insurance carrier and policy numbers are: <br /> Carrier: //--7 R-T Policy Number: <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: e13,111 Signature: <br /> Print Name: 4 <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 /> T ZAT1 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ,to <br /> sign 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 /> EHD 29-01 07/20/10 <br />