Laserfiche WebLink
_ San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: __ _ _.__�_ 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#: �ft (Q3�J1 Exp Date: <br /> Date: _ �' _ Contractor: t'1''P_C..t 't W1 r m Q i i►�Ot <br /> Signature: b19=7-- Title; -- <br /> Print Name: dJC�1l �a'- crate <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 CA are: <br /> Carrier. L1n?&1A 1 M Policy Number: C gn t.A <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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor <br /> -Code, I shall forthwith comply with those provisions. <br /> Exp. Date: tP 13� Signature: <br /> Print Name: craui--VA� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000, 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 /> AUTHORIZATION Fpf OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ty) �-. C rv` (signature of C-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 the authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> ."U1.PERMIT♦i- <br /> E1A 2441 014M10 <br />