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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> .;costa Airprrt. Way, itu�ktor„ Cali€orrice <br /> .. ^f Rs gl-c r,:: 'ria o.^, z�c+t:n�i a ,":IIp r ,-..:.. <br /> JOB ADDRESS: 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#: cl 5`7- :71M-7q Exp Date: '713 111201 <br /> Date: Contractor: Gj�otr_x o <br /> fTitle: C <br /> Signature: t t� � <br /> Print Name: (,� f'l r') VV1.7C)0L<)dQ) <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: ro Mc'oQ, Cot SfrC/ Policy Number: 00,(L 2:7/(77�0 <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 Cade, I shall forthwith comply with those provisions. r�j / <br /> Exp. Date: / / I �� Signature: ice" v`1064!x-' j <br /> tl <br /> Print Name: l �}/1�'�fir; �• � <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 /> + AUTHORI ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 (signature of C-57 licensed authorized representative), <br /> hereby authori (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 /> plan dated on the front page of this application. <br /> EHE)29-01 05`09172 WELL PERMIT APP <br />