COMPLIANCE INFO_2015-2016 - Laserfiche WebLink

Home Browse Search

San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL 1120 Frewert Rd, Lathrop, CA 95330 JOB ADDRESS: APN 191-270-05 PERMIT SR #: LICENSED CONTRACTORS DECLARATION I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. Contractor Name: California Pacific Drilling License #: 766402 Expiration Date: 07/31/2017 Signature: Title: Owner/Operator Print Name: Elliott D. Vande Poppe Date: 08/29/2016 WORKERS' COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: (check one) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. I have and will maintain workers' compensation insurance, as required by Section 3700 of the ® Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: Admiral Insurance Company Policy #: 9098420-16 Exp. Date: 05/05/2017 I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, and agree that if I should become subject to workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply with those provisions. Signature: Print Name: Elliott D. Vande Poppe WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION , hereby authorize _..........N— of C-67 Ucanaad AuMoruad Rap m r*.W- Prim Nana at Aut-d-d Again to sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. posture of C -P Lic .d Au rued Ap..emsbaa EHD 29-016-23-2015 Site Mitigation Well Permit Application