Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 5756 Pacific Avenue, Stockton California PERMIT SR#: <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: Sierra Tech. Services, Inc. <br /> 31 <br /> License#: C_ 9 309 Expiration Date: 31 <br /> l <br /> Signature:_ Title: nr t)tJ ,,r- <br /> Print Name: VJ / ltfre- Date: 0� C/ 6' <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 /> 13 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 /> 0 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:`7t4&CGnt):) IYtS %U�rt Policy#: l"I ')3?J1 Exp. Date: ltcrl } <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':cor�hpensation provisions of Section 3700 of the Labor Code, I shall <br /> ,forthith comply with those provisions. <br /> Signature: �— <br /> Print Name: ! " <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 /> hereby authorize nn[Name a <br /> a xBnsctlA ,IR4 Pinx'^GGve AUTO gent <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 /> 5 grtature cenmE A ORCU aprtmnYhw <br /> EHD 29-016-23-2015 Site Mitigation Well Permit Application <br />