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� r <br /> San Joaquin County Environmental Health Department <br /> WELL <br /> & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: LLCI r �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 /> License#: tP3(0 33-7 Exp Date: 112- 112-012— <br /> Date: <br /> 'a1IZo12— <br /> Date: _ Contractor: WC4SIOrJ 5�4MOL- 06, in1G <br /> Signature: �--� Title: OPFAA-TIONS I44-rJA6EK <br /> Print Name: e)R FIJ'bk COA- l FOIA <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 work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier:_ SW-h-'Ighk a5u In - Policy Number: _e2PjII,-j9m,4 <br /> I 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 prvisions. <br /> Exp. Date:_ tp 15011- — Signature: Ll— <br /> Print <br /> l ---Print Name: $1tFil)D CKA-WFOA-0 <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS 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 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' $RFPIPk CA,4WF0" (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this auth ization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHo zs-oi 07rz&10 <br /> uowWELL PERMIT APP <br />