Laserfiche WebLink
,. !A tf I a <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 5950 E.Woodbridge Rd.,Acampo,CA PERMIT SR# <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#: 7 0904 • Exp Date: April 30,2015 <br /> Date: CQntr ctor: , nl 1 <br /> ) <br /> Signature: Title: Err5l J��Z—L <br /> Print Name: <br /> WORKERS' COM PENSATI 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 ins rance rrier and olicy numbers are: I� <br /> Carrier: ��9 Policy Number: �v <br /> 1 certify that in the performance of the work for which this per is ' I shall not employ any <br /> person in any manner so as to become subject to the workers' ompens ion law of California, <br /> and agree that if I should become subject to workers' compensate n provisons of Sec ' n 700 of <br /> the Labor de, I shall forthwith comply with those rov' ion . <br /> n r%. <br /> Exp. Date: Signature: <br /> �6 )Q <br /> Print Name: v 11 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPL ER TO <br /> CRIMINAL PENAL-.TIES' D CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S F ES,AND 9AMAGES AS OVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> t <br /> MO <br /> I ION FO OTHE THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorizQmehalf. <br /> t name , to sign this San Joaquin County Well & Boring Permit <br /> Application on I u derstand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />