Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 666 West Weber Street,Stockton, CA 95203 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 thh(e California Business and Professions Code and my license is in full force and effect. <br /> License#: -1S3 u' L� u, Exp Date: 1y I _� ZUl <br /> Date: lI 115 Zo I Z- Contractor:�( /�/1 u�+ ����• �+ <br /> Signature: ' � — — Title: �/i /r I Lt --el" <br /> tj <br /> Print Name: ftiw\ <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 /> 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: `-v t\ cL. h "%-{ l I (6N el Policy Number: W(1C` 1 C`l, :515 -0 C� <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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 2 J( > Zc�12 Signature: �� 7 <br /> —r <br /> Print Name: CRaAf� <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 /> AUTHOt RIZATION F R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> C�n1�5 ltg' ,t� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) y�I2 /nu,n 'T to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I 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 /> EHD2"I 05N 12 WELL PERMIT APP <br />