Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 14--100 Ha ✓14uh r as � PERMIT WP#: <br /> Lo-R/-roP, Cit f 3C) <br /> LICENSED CONTRACTORS DECLARATION <br /> I hereby affirm that 1 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 /> Contractor Name: 9int�I VDV 'VIe IA'c ,i GO AJ-Vn I lT5>UC l ct+Ze, 5 A) <br /> License#: S Expiration Date: 9 / 30 �/ 43 <br /> Signature: <br /> Title: CJw a I <br /> Print Name: Ilw, ��t%f Date: ly /lb( li <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 /> ,d I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> y� 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:SiT 't- / 'Fvvp\A Policy#: j 9 ��� U q(, " )-i Exp. Date: <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers' compensation law of California, and agree that if I <br /> should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Signature: <br /> Print Name:_ l„t, Ty <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (I e, (y(f.✓ , hereby authorize <br /> to sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this <br /> authorization is valid for one year and is limited to the work plan dated on the front page of this application. <br /> -- 9ipnW IC.SI Lk.n.G luNenaM Pµv.,,nladv. <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />