Laserfiche WebLink
San Joaquin County Environr _.. Health Department Unit IV Well Permit A�,,r,,• ation Supplemental <br /> JOB ADDRESS: 2801 West Lane,Stockton CA PERMIT SR# 3 <br /> LICENSED CONTRACTORS DE LARATION (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 force and effect. <br /> License##: _ !q �5 (a eJ Exp ate: <br /> Date: Contractor: <br /> Signature: Title: <br /> Print Name: CY- <br /> 3 <br /> WORKER'S COMPENSATION DECLARATION <br /> I <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 p rformance 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 /> i compensation insurance carrier and policy numbers are: <br /> Carrier: ����r r h_t . /373 10? 2(0 <br /> 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 theworkers'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' 4_f.J {�)n Signature. <br /> Print Name: <br /> I <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UN[.AWFUL,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 706 OF THE LABOR CODE. <br /> THTION FOR OTHER THAN C-57 SIG ING PERMIT APPLICATION <br /> 1, (signature of -57 licensed authorized representative), <br /> hereby au rize(print name) Anhony Windling,URS Corporat on ,to <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 pag a of this application. <br /> Rl29Ir�2lMl <br /> E1402"I 1915!07 WELL PERMIT APP <br /> ji <br /> 6 <br /> 1� <br />