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1 San Joaquin County Environmental Health Department <br /> i WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> II <br /> JOB ADDRESS: W a� 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 #: Slns7 8 —EtxxpDate: 5 ' 31 � zw l <br /> Date: O orifractor. / EST�YYJ£l�fCe4 bR1U AJC <br /> Signature: �� Title: /r1% dri <br /> Print Name: d <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 /> 1 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 /> compensa��tioo'n insurance carrier and policy numbers are: / <br /> Carrier:'Ilil� f'.���.N0UoJ4C C ta�Pollcy Number: <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 1 should become subject to workers' compensation provisions of Section 1700 of <br /> the Lab i/or Code , I shall forthwith comply with those pro 'on . <br /> Exp. Date: �{ Signature: r <br /> Print Name: Ivt ewaL 167 . 4Akodi <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE 13 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 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C57 licensed authorized representative), <br /> hereby authorize (print name) , 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. /� —��� /Z 72 <br /> EHD n9 l OltW O v WELL PERWT APP <br />