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JOB ADDRESS: <br />San Joaquin County Environmental Health Department <br />WELL & BORING PERMIT APPLICATION SOPPLEMENTAL <br />2255 S. Airport Way, Stockton, CAPERMIT 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 #: <br />C-57 #906899 <br />Exp Date: i.I I / `— t <br />Date: � l - Contractor:1-�> <br />Signature: <br />Print Na g::�-~ ?' Gm6 Ah <br />Title: �! <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 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: b 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, <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 />ATT <br />OBN7S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />,;:_%j i <br />HORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />(signature of C-57 licensed authorized representative), <br />r <br />authorize (print name) &j&o 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 />EHD29.01 05MO112 WELL PERLM APP <br />