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r , <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: U 1 wG J PERMIT SR# <br /> ! "ZJ L*n <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 California Bu si ess and Professions Code and my lice'nsfI i in ful force and effect. <br /> License#: Exp Date: `I ��� 1�(,7 <br /> Date: { C� )contractor: C�t ��� E� ! 11 )n C <br /> Signature: / _ Title: C�9 G <br /> Print Name: <br /> WORKERS' ( A N DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 /> compens insurance rrier and policy numbers are: <br /> Carrier: k > Polr. Lf icy Number I/C)�� � ;-- ?0,`L <br /> I certify that in the performance of the work for which this permit is issu"%ssiatio <br /> all not employ any <br /> person in any manner so as to become subject to the workers' complaw of Ca. omia, <br /> and agree that if I should become subject to workers' compensation pr vison of Section 00 of <br /> the Labor C de, I s all forthwith comply with those provi ions. <br /> Exp. Date: -� i 4 Signature: 440 <br /> Print Name: <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 /> ATTORNFE S,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTH R TION FORK THER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, ) L (signature of C-57 licensed authorized representative), <br /> hereby authori (p nt name) t (rW C''k to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 u rst'a d 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 05MI2 WELL PERMIT APP <br />