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X010 <br /> k <br /> San Johquin County Environmental H alth Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL_ <br /> JOB ADDRESS: �D .I��y, , PERMIT SR# <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 /> LicenseExp ate: 1 3 t 2-012- <br /> Date: Ln)Ib 'Contractor: Nk ci$tvhl S4-M.i0t-I0&, G. <br /> Signature: Title: 0iQ *-Pm0AJs l-A-NA{E <br /> Print Name: 6 R FP bA- GILAW F=Of-b <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 elf-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for t e performance of the work for which this <br /> f <br /> permit is issued. <br /> !� I have and will maintain workers' compensation insurance. as required by Section 3700 of the <br /> i 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 /> r COHWOJID J PKOR6%4-� <br /> Carrier: "D CA-5V Policy Number: Ute` 1041&(a <br /> } I certify that in the performance of the work for which this permit Is issued, I snail not employ 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' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr vi ions. <br /> Exp. Date, (a 30 2.0 i t Signature: <br /> Print Name- DA GV-RviFO" <br /> WARNING-FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE Is.U 4LAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,004, IN ADD ON TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 17CIS OF THE LABOR CODE. <br /> AUTHORIZATION FOR-OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l 6R�P- G4-Awro� <br /> 1, _ (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 1�'1 I 1 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 /> 'EmO248:07!1&10 V&U PCRZMJT,uP <br /> i <br />