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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 3212 North California Street, Stockton,CA 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 Iny license is in full force and effect. <br /> License#: 953 64 7 Exp Da(e. 10/31/14 <br /> Date: 5/x6/13 Contractor: National EWP <br /> Signator Title: Project Supervisor <br /> Print Name: Kenneth B Cook <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 /> x I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the worst for which this permit is issued. My workers' <br /> compensation Insurance carrier and policy numbers are: <br /> 1 Carrier: AttachedAttached <br /> Policy Number: <br /> C1 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 workers' compensation law of California, <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 Prov' ions. <br /> Exp. Date: 8/5/13 5ignatur <br /> Print Name: Kenneth 13. Cook <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 19 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 370$OF THE LABOR CODE. <br /> AUTHORIZAT ONI FOR OTHER THAN CZ7 SIGNING PERMIT APPLICATION <br /> C 5 _, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Appllcatioll 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 /> 0020-0 0sU,2 <br /> weir rErrHirAIa <br />