Laserfiche WebLink
INS <br /> EH0 29-01 07120110 WELL PERMIT APP <br /> San Joaquin County Environme ita'I 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 Business and Professions Code and my I cense is in full force and effect. <br /> License #: LEI Exp Date : i �)\ I N - <br /> Date : `�I U 'Z Contractor A� � <br /> Signature : T— � `� – – Title : . _ CJ �A <br /> PrintName: <br /> WORKERS ' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the followini t declarations : (check oneN <br /> I have and will maintain a certificate of consent to >elf-insure for workers' compensation , as <br /> provided for by Section 3700 of the Labor Code , fc r 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 /> compensaatiion, insurance carrier and policy numbe s are: <br /> Carrier. \i l \ -e u , Policy Number: JC1 I <br /> I certify that in the performance of the work for whish this permit is issued , I shall not employ any <br /> person in any manner so as to become subject to he 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 previsions <br /> Exp. Date: LI I I I .L Signature: . .- -� <br /> Print Name: _ L jA S1( I C 11 p <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 AUDITION TO THE.COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SE ::TION 3706 OF THE LABOR CODE . <br /> AUTHORIZATPON ,EOR.OTHER HAN CmS lip SIGNING PERMIT APPLICATION <br /> i ��� — (signatureof C-57 licensed authorized representative), <br /> ; <br /> hereby authorize (print name) w_ 0e� Z; (I ( �I I UCLALOl i j , 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 /> EHD 2901 07120110 NEI l PERMIT APP <br />