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PERMIT E ) �iL" <br /> Fermit may have expired <br /> San Joa' 9 , Imo' ay9 aiMent <br /> WELL & Bo"4:fMWr4I"6J gkl nnENrAL <br /> JOB ADDRESS: PERMIT SR <br /> LICENSE® CONTRACTORS DECLARATION {LCA) <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#: �`3('9 Exp Date: !/ a 1'l 2-012-- <br /> a <br /> Date: I �t�--' Contractor: P fl"G S I®h1 in t-1,+J h� /iJ6. <br /> Signature: Title: 14A--fJAr6&X <br /> Print Name: <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:_ Sw_kn-Igh+ 5U1a'(ic.C) Policy Plumber: VM)co(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: signature: <br /> Print Name: 6"�J D A FO® -0 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5'100,000, 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 /> 1 b A-e; >Af:�Ol�-a� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)-TUT1l�V �l to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this auth rization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. /l j <br /> EHD29-01 07/23!10 V"L.N4 1 -WELL PERMIT APP <br />