Laserfiche WebLink
I San Joaquin County Environmental Health Department !alit IV Well Permit Application Supplemental <br /> -7 <br /> =' ADDRESS: 5 i 00 1114)qh LAO 1/ 33 PERM T S <br /> Te n a/ -- "' <br /> LICENSED CONTRACTORS CECLAPAT!ON (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 3usiness and Professions Code and my license is in full force an ' effect. <br /> License#: Exp Date: <br /> Date: /S- i = Contractor: <br /> 1 Signature: �7 , Title: L-�F- c <br /> Print Name: 4 e--f� <br /> r <br /> WORKER'S COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i 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 /> 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 /> =mpensation insurance carrier and policy numbers are: <br /> Carrier: SLA t-, c 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 the workers' 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: f/, j ' Signature: Z ;-� <br /> Print Name: <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 /> AUT RIZ TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby out size (pr' t name) (� ( � S/� /� S�T- 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 page of this application. <br /> I <br /> 2i291021M! <br /> EPD 2c 47 t i/W 'AELL PERM?-A- <br />