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FHU 10W 011M,I, WEII Il 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 Business and Professions Code and my li tense is in full force and effect. <br /> License#: g� �,`1 _ Exp Dale: t\I(r.11)'' <br /> Date: (_ ii ,t�\ l-1 r Contractor: <br /> Signature: <br /> Title: - <br /> Print Name. L11 I I 1 <br /> WORKERS' COMPENSATICN 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 /> CI 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 number:are: <br /> Carrier: \(A\t" V1 A I� Policy Number: <br /> 1 certify that in the performance of the work for whici this permit is issued, I shall not employ any <br /> person in any manner so as to become subject to If a workers' compensation law of California, and <br /> agree that if 1 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:\k f t't)1 0 A t i I Signature: <br /> Print Name:_,) <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 ADVITION 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 /> Linl'!h-0III/gG'10 WELL PE«41I1 M1PP <br />