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9 A, UJD <br /> San JoaqL. ::ounty iwnvironmental He Ith Departmen <br /> WELL & BORI1 G PERMIT APPLICATIO SUPPLEMENTAL <br /> ,�pr/ <br /> JOB ADDRESS: �231 S 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) or <br /> Division 3 of the California Business and Professions Code and rhy license is in full force and effect. <br /> License : (03&0 3�—] Exp ❑ te: t 13 11 2-01 Z <br /> Date: /2, �l Contractor: MECASIV&l SA-M O to A)6 A1C,. <br /> Signature. ; Title: 0WI OAJS MA Ar6&-K <br /> Print Name: <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 /> 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 whi h this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carr1ler:__SR6L,LYZJ�1* 1 Policy. umber;. <br /> 1 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 orkers' compensation law of California, <br /> and agree that,if I should become subject to workers' Compensation pensation provisions of Section 3700 of <br /> the tabor Code, I shall forthwith comply with those pr vis ons. <br /> Exp. Date: I I Signature: <br /> Print.Name: D A C4LAFi1" <br /> WARNING:FAILURE TOSECUREWORKERS'COMPENSATION COVERAGE IS UNI-AWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION 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 /> I, 61ZEP1>A- (signature of -57 licensed authorized representative), <br /> hereby authorize(print name) Its , to sign this San Joaquin County well s 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 /> he-et^I <br />