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I, San Joaquin County Environmental Health Department WELL & BORING PERMIT APPLICATION SUPPLEMENTAL JOB ADDRESS: COS�v1�'y�%�p; PERMIT SR # LICENSED CONTRACTORS DECLARATION (LCD) I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the California Business and Professions Code and my license is in full force and effect. License Exp Date. Date: f�% �� Contractor: Signature: "�� /„� � Title: C�,��G cY/iG/�s /1�liGCr�ctY Print Name: ' Pte'- I WORKERS' COMPENSATION DECLARATION I I hereby affirm under penalty of perjury one of the following declarations.- (check one) i i I have and will maintain a certificate of consent to self-insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this t permit is issued. # I have and will maintain workers' compensation insurance, as required by Section 3700 of the I Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy numbers are: Carrier: Policy Policy Number: i I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation law of California, i and agree that if I should become subject to workers' compensation provisions of Section 3700 of j the Labor Code, I shall forthwith comply with those provisions. I Exp. Date:_�� //, Signature: a ,i<1;�_ n j Print Name: i WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. dUT RIZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION I, L-• _ (signature of C-57 licensed authorized representative), hereby authorize(print name)1\d h i r,} C- �r)C)z ?,)to sign this San Joaquin County Well S Boring Permit Application on my behalf. I understand this authorization is valid for one year and is limited to the work plan dated on the front page of this application. I � EHD 29-01 05103/12 WELL PERMIT APP - - ----.fir_._. _. - ...................._....---- -