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San Joaq; county Environmental He lth Departmer,_ <br /> WELL & BORING PERMIT APPLICATIO 4 SUPPLEMENTAL <br /> JOB ADDRESS: V57 E , A/ - PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby-affirm that I am licensed under the provisions of Chapt r 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 n: �3 3$� Exp Date: t -111 2-012-- <br /> Date: <br /> 012-Date: �, �2- Contractor. PO S 10+3 SAM.IAu a6 rJ6, <br /> i <br /> Signature: ; <br /> Title: OPS 00S MA A <br /> PrintName: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following decla ations: (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 /> l� I have and will maintain workers' compensation insurar ce, as required by Section 3700 of the <br /> Labor Code, for the performance of the work for .whi h this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier; J. A.LrIC�JTI_ '_lr) J rlCP— Policy urnber: <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 theworkers' compensation law of California, <br /> and agree that.if I should become subject to workers' compensation pensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr vis ons. <br /> Exp. :Date.. -S 0 1 2.0 Signature: <br /> Print Name: D CAL-AW Fi�7w_4) <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES ANO'CIVIL FINES UP TO$100,000, IN ADDM N 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 /> It 6gep't>A C.*_Ar%k)"V_-b (signature of -57 licensed authorized representative), <br /> hereby authorize(print name) M j l&kc. - , to sign this San Joaquin Bounty Well & .Baring Permit <br /> Application on my behalf. 1 understand this aut rization is vali for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> It <br />