Laserfiche WebLink
San Joaquin County Environmental <br /> q ty ental Health Department Unit IV Well Permit Application Supplementsl <br /> j on Ri Ave,t <br /> St <br /> S. Stockton <br /> E[ JOB ADDRESS: 519 SP 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 license is in full f rce and effect. <br /> License#: 1)51 Exp Date: A—�tllt� <br /> a <br /> Date: �0 p b Contractor. NQ vllll/I <br /> Signature: ti. _ Title: eC y-1s �Uwjxr <br /> Print Name: �J 1 J�,Oe / <br /> WORKER'S 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 are: kk\( <br /> Carrier: %R Amur Policy Number: <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, 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 provisions. <br /> Exp. Date: ��( (�\O Signature: <br /> Print Name: C°�Yt'IUV�I� 1"rN/le/ <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 ADDITION TO.THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> 8 TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby a thorize (print name) Binayak Acharya to <br /> , <br /> sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br /> for one year and is limited to the work plan dated on the front page of this application. <br /> S/29/021M1 <br /> EHD 29.01 11IM7 WELL PERMR PPP <br />