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AdIlk <br /> EHD 28-01 07120110 <br /> WELL PERMIT NPP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2d0 �' WmAV✓ A ��o�1�D.. <br /> PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of APF <br /> Division 3 of the Business and Professions Code and my license Is in full force and effect. <br /> License#:6-" Exp Date: <br /> Date: 6 ! q �/ `Contractor: <br /> Signature: n om— Title: 14191:2- ser <br /> Print Name: lam✓/!G! {'/GI//�� <br /> i <br /> WORKERS'COMPENSATION DECLARATION <br /> i <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 which this permit is issued. My workers' <br /> compensation insurance Carrier and policy numbers are: <br /> Carrier: Rcorw Policy Number: �9/C�0/0 >&I/O 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, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, 1 shall forthwith comply with those provisions.�,// <br /> Exp. Date:-R.(34117 - Signature: n <br /> i <br /> Print Name: // r— /! G✓/IF/ <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 0706 OF THE LABOR CODE. <br /> U RIZ FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1. (signature of C•67 licensed authorized representative), <br /> hereby aut orize(print name) to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. 1 understand this authorization <br /> is valid for one year and Is limited to the work plan dated on the front page of this application. <br /> EHDN9 f 011DX10 <br /> WELL PERMIT MP <br /> ( <br />