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X+L Cos• A&W• 3 <br /> Sari Joac, County Environmental Health Departme, <br /> WELL& BODING PERMIT APPLICATIO 4 SUPPLEMENTAL <br /> JOB ADDRESS: 231 +� (iAL l 2 rVl PERMIT SR# NP3 6 6 <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#: (a3.(,g 3$-7 Exp D te: 3— <br /> Date: �, �2, Contractor: f f E S I CW S"O W A)& lJC,. <br /> Signature: Title: Opt' vAjs mA--# JAG&x <br /> PrintName: <br /> WORKERS' COMPENSATION DECLARATION <br /> 1 hereby affirm under penalty of penury one of the following decla ations: (check one) <br /> I have and will maintain a certificate of consent to se f-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 /> X I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier:_-I�nl/ _Yl%,Q� Policy umber: l <br /> I certify that.in the performanceof 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 provisions of Section 3700 of sl <br /> the Labor Code. l shall forthwith comply with those pr ons. <br /> Exp. Date: 30 f 1.0 Signature: <br /> Print Name: DA Fin" <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $400,000, IN ADDITION TO THE COST OF COMPENSATION. INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 37)6 OF THE LABOR CODE. <br /> i <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, b 1zFwDA (signature of -57 licensed authorized representative), <br /> hereby authorize(print name) to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this aut rization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> wEu p-cRun PP <br /> i <br />