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EHD 29-01 07/20/10 Iwo WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> ' WELL &BORING PERMIT APPLCCATION SUPPLEMENTAL <br /> JOB ADDRESS: 1Z5,5 5owksA�r v,r W I 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 Business and Professions Code' _and my li:,-ense is in full force and effect. <br /> License#: 'Exp Date: - <br /> i �n�n <br /> bate: Contractor: _81 o d `nt <br /> Signature: - Title: - <br /> Print Name: <br />'I WORKERS' COMPENSATICIN 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 theerform <br /> p once of the work for which this permit is issued. MY workers <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: A-e V Uc A Policy Number: 1" -1.2—D- <br /> I certify that in the performance of the work for whic1 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 thaflf l-should b®come°subject t6-"w0rkers'coiinpensafion provisions of Section—T760 of the <br /> Labor Code, I shall forthwith comply with.those provisions: <br /> Exp. Date: Signatures:-' <br /> Print Name A <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE VS 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 SECINON 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING <br /> PERMIT APPLICATION <br /> (signature of C•57 licensed aut orized representative), <br /> hereby authorize (print name) Q 26 , p J3JLKuGl�N O <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> Is valid for one year and Is limited to the work plan dated on the front page of this application. <br /> EHD 2MI 07r10110 WELL PERMIT APP <br />