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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: I�tG C J, n b ` ytco 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#: (03(,a 3'?-7 Exp Date: 113 I1 2-012— <br /> Date: <br /> ot '—Date: Contractor: P14EGI5I171.154MOL /Jk, an1G. <br /> Signature Title: OfE/LA FfJS LtMJA`6EFK <br /> Print Name: �JQEIJ�fV CGkA-1JF-0f--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 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:_ Sea b-'lghk 2h$Ij tanGO Policy Number: �6I I13ylo�O <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 pr vi JJs. <br /> Exp. Date:_ 1.0 15011 2— Signature: L---- <br /> Print Name: DA C4-AkAJll <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$700,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> bRFIJbOc C4, Wf: Q0" (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 /> EH029-01 01fZBI101 , �� /� n�� WEL'.PERMIT APP <br />