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PERIVIi <br /> Pe it <br /> San Joaquin County Environmenial f1r�p: <br /> WELL & BORING PERMIT APPLIC 1 �w�Kib <br /> 9�� mental y ,x,7 1%paqILId <br /> JOB ADDRESS: SqO �+�' �� jl;f l PERMIT SR # 17 <br /> SEQ <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 <br /> /California <br /> fBusiness and Professions Code and my licenssej is in full force and effect. <br /> License#: 7;, 0 /"I Exp Date: <br /> Date: //, I/ Contractor: (4 AleeV EX#O)-,, <br /> Signature: -7�2 / - Title: ouil er <br /> PrintName: /�5 <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: 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 provisions. <br /> Exp. Date: Signature: '/ <br /> Print Name: Jd4n J�l"S <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 11 ©" P1 r/,3 (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) !�$�, to 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 /> EHD 29-01 05/09/12 WELL PERMIT APP <br />