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May 03 2013 10:03AM Sage 9724809865 page 2 <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 300 South Beckman Road, Lodi,California PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LD) <br /> 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#: 705927 Exp Date: <br /> Date: 4"22-13 Contractor: UIronex <br /> G4 iy1 ,, <br /> Signature: 1 Title: �.- <br /> Print Name: <br /> WORKERS'C MPENSATION 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: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUWECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S PEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZA <br /> TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, Wa +t SS4y (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)B�c-� 410 _` , 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 /> EH020.01 05IM2 WELL PER WT APP <br />