Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 47y Vtr �� �� � � ��Y' �� Rau"' PERMIT WP#: <br /> 5-�v_-�o v\, C Q S (o <br /> LICENSED CONTRACTORS DECLARATION <br /> 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 /> Contractor Name: &wv1w_oAe -,ko,\ octet S 1 L,( �( A <br /> License #: Expiration Date: (� 50 /1,6 <br /> U�� <br /> Signature: l--.-„ Title: e—" <br /> Print Name. Date: <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 /> 0 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 are: <br /> Carrier: j fie, �fUA ` Policy#: 1cl ZC7'�lo )� Exp. Date: <br /> 1 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 /> 7- Signature: <br /> Print Name: I two 1�e_C <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 rr AA <br /> vAn ,e'/ hereby authorize �° �'• <br /> GV�" Nth ✓Uols� <br /> Name of C-57 L-1—d AuMori Ropnnanl ,* PAM NN- of AUMonad Ap-t <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 i limited to the work plan dated on the front page of this application. <br /> ignafura of C-57 Llcanaad Aufhorlud Rapnssnu v <br /> EHD 29-01 8-1-2017 Site Mitigation Well/Boring Permit Application <br />