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San Joaquin County Environmental Health Department <br />WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br />JOB ADDRESS:V) M S 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 California Business and Professions Code and my license is in full force and effect. <br />License #: 103 % 3'? -7 <br />Exp Date: I 3 i 0q0 Iq <br />Date: 13 1 Contractor: PlklFCA S ( ®til 5A4 -40L -4A)(,, I)JG . <br />Signature: Title: 0K­A,4--'ivNS RA-RJ41SEF4 <br />Print Name: e) Qep-bAr G2 -4w F0lub <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:_ S2lx.�DN-`%gh+ aSUKIM,1&0 Policy Number: 66I 1 T)9A0(P <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 pr visions. <br />Exp. Date:_ t0 t 50113- Signature: <br />Print Name: 60-u D A Cit A W R - <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 />AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, b R.FP'1PA C*-, -W Fob (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) li6v� 115�t, sign this San Joaquin County Well & Boring Permit <br />Application on my behalf. I understand this a <br />plan dated on the front page of this application. <br />is valid for one year and is limited to the work <br />EHD 29-01 07/28110 l� WELL PERMIT APP <br />UT -a <br />