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END 2e-al c7not3u <br /> 'A''FLL PERMITAPP <br /> San Joaquin County Environmental Heafth Department <br /> WELL St BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDREISS: _ PERMIT SR ft <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 license is in full torte and effect. <br /> License#: ��_(,r�� , Exp Date: 1 1'?) <br /> Date: it-D X- l l Contractor: e- v z f it1tlf�C+ . <br /> Signature: iJ7/Y241(ZJ1lw Ill Title: 4 <br /> Print Name:_1�Ctit1p4,_# L�cjn[�t•f.t C� <br /> v <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one Of the following declarations:(check true) <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!s issued. <br /> I have and will maintain workers'compensa ion 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:5P:QLNb trgl._}__111a.. �\-a � Policy Number-ablim$_(-- <br /> I codify that in the performance of the work for which this permit I$issued, I shall not employ arty <br /> person In any manner so as to become subject to the workers'compensation law of California, and <br /> agree that k 1 should become subject to workers`compensation provisions of Section 3700 of tite <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Date: 10-1-tom Signature: <br /> A <br /> Print Name: <br /> WARNING;FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE,IS UNLAWFUL,AND SHALL$UBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FIRES UP TO S;00,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR COOF_, <br /> AUTHORIZA1TIION�FOR.OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-67 licensed authorized representative), <br /> hereby authoriz (print name) ai to :zC)ndh I k a <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 /> "021101 <br /> Ntlt PrranrnPP <br />