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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �—I UJ-0�( m LIQ 1V" (-)\U ( 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 for a and effect. <br /> License#: & Exp Date: --11)131 / <br /> Date: Contractor: h,?V1t <br /> One— <br /> Signature: ��� Title: <br /> Print Name: 1 K I "D � T U H <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 /> 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: Q 2 n� <br /> Carrier:21,l .�IA r� hAtaA Lt7hfAl�llLt!P Policy Number: 1 9314 n2�f <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 ode I shall forthvrith comply with those provisions. <br /> Exp. Date: Signature: <br /> Print Name: ( I�TIrI LLt i <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 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 /> THORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> l (Signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) �'; TLV to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> END 2901 050112 WELD.PERP T APr <br />