Laserfiche WebLink
r.. <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> FIDivision <br /> ESS: 14749 N. Thornton Road, Lodi CA PERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> ffirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> of the California Business and Professions Code and my license is in full force and effect.969758 Exp Date: 2/29/2016 <br /> Date: March 11 Contractor: Ar,2 F'nyi ronmeatal <br /> Signature: — ^" "^ Title: General Manager <br /> Print Name: Scott Traub — <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 /> X 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: Travelers Policy Number: DTJUB7E79315 <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 work tion law of California, <br /> and agree that if I should become subject to workers' cam tion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr <br /> Exp. Date: 6/30I2015 Signature: <br /> Print Name: Scott Traub <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND$HALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES I)LOAM&GE$AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ,,- OF4ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, {signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) Tim Cue , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHDM-0I U7R&10 WELL PERMIT APP <br />