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RW CID it <br /> San Joan,.. ; ounty Environmental He Ith Departmet,._; <br /> WELL.& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB.ADDRESS: C) N, C� L J�Q/�/U/4 I�PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapt ir 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and rhy license is in full force and effect. <br /> License#: 103 313-7 Ekp Dz te: - <br /> Date: l2 Contractor: P1IkE S(01.1 SA-M OLA A)& AJC_. <br /> Signature: Title: 0OU o►u5 14"A7601, <br /> Print Name: �R,EJ�-y�fk Gtr-�1�1>CDI�$ <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 /> 1 have acid will maintain workers' compensation insurance. 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:�Y' t�T1lalPnC _ Policy umber: �, L I 'T1 _ t0 <br /> I certify that in the performance of the work for which this permit is issued, I shall not emplay'any <br /> person in any manner so as to become subject to the workers' compensation law of Califomia, <br /> and agree that,if I should become subject-to workers' cot ip6nsation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr vis ons. <br /> Exp. Date: [3 01 2.0 Signature: <br /> Print Name: D A <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5700;000, IN AODM 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 ]PERMITAPPLICATION <br /> 1. b l ww, C*4,*WF�0 (signature of -57 licensed authorized representative); <br /> hereby authorize(print name) ctk � �`` , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this a rizatiori is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> _tinea:.. +rrrr�a �I heeyl w ?=Rlrrr�a? <br />