Laserfiche WebLink
San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOBADDRESS: t JL4 l,� J�Z�.+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 California Business and Professions Code and my license is in full force and effect. <br /> License#: C `��' �b-f Exp Date: <br /> Date: Contractor: <br /> r <br /> signature: ^---- Title: ®.o& A► rGGrL /2AYY3�- <br /> r <br /> Print Name:— prceene- <br /> WORKERS' <br /> COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> 7"� <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> P <br /> rovided for by Section 3700 of the Labor Cade, 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: rl�� Policy Number:&/C(,V9/O %/�1(2/ <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 ode, I shall forthwith comply with those provisions. <br /> Exp. Date: g Signature <br /> Print e: <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 /> All R ION FOR OTHER T -57 SIGNING PERMIT APPLICATION <br /> i, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , 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 /> pian dated on the front page of this application. <br /> EHD29-01 05=112 WELL PERMIT APP <br />