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i <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL ` <br /> I, <br /> I <br /> JOB ADDRESS: /3 3 CAST 0_#A9Te0Z lil/Ay PERMIT SR# <br /> ST'OcKTvK GA I <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 Cal Ifornia Business and Professions Code and my license Is in full force and effect. j <br /> License #: Z 8 3 3 Z 6 E xp Date: Ce ( _ <br /> Date: _ �,L S 12-0/1 Contractor: � .e gr Wtc <br /> Signature;" Title: .o_!.. ,er <br /> Print Name. k pq_, <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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 insura ce, 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: y <br /> Carrier: , •!:7`U1CGt Y-) Policy Number: <br /> I <br /> I certify that in the performance of the work for which th s permit is Issued, I shall not employ any i <br /> person in any manner so as to become subject to the workers' compensation law of California, j <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the labor ode, I shall forthwith comply with those provl <br /> Exp. Date: 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$100,000, IN ADDIT ON TO THE COST OF COMPENSATION,INTEREST, E <br /> ATTORNEY'S FEES,AND DAMAGES A5 PROVIDED FOR IN SECTION 3T06 OF THE LABOR CODE. i <br /> i' <br /> AUTHORIZATION FOR OTHER THAN C-57 SIG14ING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)8FLiFW YlEA11, to sign this San Joaquin County Well & Boring Permit <br /> , <br /> Application on my behalf. I understand this authorization Is valid for one year and Is limited to the work <br /> pian dated on the front page of this application. <br /> EHD 2965 07MY10 <br /> WELL PEWreT APP <br /> I <br />