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San Joaquin County Environmental Health Department <br /> /WELL & BORINGPERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : b. 30 A4 <br /> . Cr tI I' rI1 ,5r— PERMIT SR # <br /> 5ro c: "rC A C4 , <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 #: 7 U qp �Exp Date: IV3 �VZ� <br /> V t� <br /> Date : 1 CO tractor: WA51 a n C <br /> Signature : , V Title: �R"i ICL <br /> Print Name: Ln <br /> WORKERS' COMP SATION 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 /> V�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:.5r4N (:dm 41,q SS U04 AKAJ Policy Number: U Z63tiYI Z <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 Cali ornia, <br /> and agree that if I should become subject to workers' compensation ovi ions of Sectio l 3 0 of <br /> the Labor ode I shall forthwith comply with those pro ' ions <br /> I <br /> Exp, Date: L� Zi (—� Signature: <br /> Print Name: V l )T �Jl / C� <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORN is FEES, o D AGES AS PROVIDED FOR IN SECTION 37000F THE LABOR CODE. <br /> AUT IZATI N R OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, Li (signature of C•57 licensed authorized representative), <br /> hereby authoriz ri t name) Prl( /I'44 , 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 /> EF02Ba1 05108/12 WELL PE FMP <br />