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Apr 25 11 03:37p FISCH DRILLING 707-768-9801 <br /> P.1 <br /> . 0 <br /> San Joaquin County Environmental Health Department <br /> WELL & /BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 939 /-1v. C-aliTau%iuLS�Sj-c6�7atPERMITSR # <br /> 4t <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 Business and Professions Code and my license is in full force and effect. <br /> License <br /> #: Exp Date: 1-31-M <br /> Z <br /> Date: L -25-I 1 ontractor: Fnwt t f lCr <br /> Signature: /// Title: Q/,�� <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 /> 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:,'540-k OCIV. 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: ��4J LSC 43 <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 3708 OF THE LABOR CODE. <br /> AUTHORIZAT10r4 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, -2:)'Ph7E— (signature of C-67 licensed authorized representative), <br /> hereby authorize(print name) .LC Lod/( , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorbaation Is valid for one year and In limited to the work <br /> plan dated on the front page of this application. <br /> EM029-0i OlrM10 <br /> Y.ELLPERMITAPP <br />