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EHD 29-01 07/20/10 PERMIT EWELL PERMIT APP <br /> San Joaquin County EIS, 'T ,� Mer'l%ktedItrot <br /> WELL $� BORING PERM`r� being co <br /> JOB ADDRESS: by EfIVlfOnfl181itaPERQM (1 <br /> IT SDI#IS�O <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 fo ce and effect. <br /> License#: l --�- Exp Date: <br /> Date: C, L. ��° VContractor: <br /> Signature: c l Title: <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: at Policy Number: <br /> I certify that in the performance of the work for which this permit is issued, I shall np",mploy any <br /> person in any manner so as to become subject to the workers'/cm,pensation law of C lifornia, and <br /> agree that if I should become subject to workers' compensation provisions of Section 700 of the <br /> Labor Code, I shall forthwith comply with those provisio s. <br /> Exp. Date: a' . Af Signature: a ry <br /> (( }t <br /> I <br /> I' . <br /> Print Name: �c_� .. A <br /> s <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJEGT_M 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 /> (signature of C-57 licensed authorized representative), <br /> 9 <br /> hereby authorize(print name) \_ to <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 /> EHD 29-01 07/20/10 WELL PERMIT APP <br />