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San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SUPPLEMENTAL. <br />JOB ADDRESS: 2255 S. Airport Way, Stockton, CA PERMIT SR # <br />LICENSED CONTRACTORS DECLARATION (LCD) <br />I hereby affirm that I am licensed under the provisions of Chapter 19 (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-57 #906899 Exp Date: <br />Date: a-1 J O ti3 Contractor: <br />Signature: �� Title: Ci -o__.___ <br />Print Na UGZn AhlueA <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 />X I have and will maintain workers' compensation i"nsurance,-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:' Policy NumGer: _ ,; n QJ 7 <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 Code, I shall forthwith comply with those pro v' ns. <br />Exp. Date: 1"`� Signature: <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 />ATTOSM78 FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I/ (signature of C-57 licensed authorized representative), <br />by 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 />plan dated on the front page of this application. <br />EHD 29-01 05!09112 WEU PERMIT APP <br />