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ETII)"v i (1140.'10 WE I I PI RMIr APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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/B�usinessr-ann}}d Professions Code and my license is in full force and effect. <br /> License#: 9-40)A Exp Date: <br /> Date: )11 -T" ) 1.\11 Contractor: _'7 % <br /> Signature: Title: _ <br /> Print Name:` i 1� � W <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 s--If-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: k � ', t Policy Number: allrill! <br /> I certify that in the performance of the work for whic"I 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'ccmpensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp: Date:-U– Et \� A t L�' IM Signature: _ <br /> Print Name:— � ('P3 �I)f_Ttlf <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 SEC"ION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (Signature of C-57 licensed authorized representative), <br /> hereby authorize(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 tie front page of this application. <br /> ' 9'$64, IV,bHO WELL I'F.!(nAII MF <br />