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10/12/2012 09:30 530--8c 1638 FEDEX OFFICE 5 PAGE 02 <br /> I <br /> y San Joaquin County Environmental Health Department <br /> WELL & e.ORtNG PERMIT APPLICATION SUPPLEMENTAL <br /> JOB AI?bf7ES5: y� PERMIT SR ff <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 /> ��� � �� � 1 1 <br /> License#:C,S-7 � Exp Date: <br /> Date: <br /> �e <br /> Signa _ �`=-. ._">. ` r Title; ;' _tJE_r �y— ^�'-L <br /> � <br /> Print fume: � �it._ C +j U <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (ahzck one) <br /> I have and' will maintain h certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 37100 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: <br /> Carrier:_._ C^� Policy 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 I should become subject to worker,,' compensation provisions of Section 3700 of <br /> the Labor Code, i shall fortlhwith comply with those provisions. <br /> r3 <br /> Exp, Bate: il-r°f 5— t' <br /> T._{�7s Signature; <br /> i Print Name:_ It� PVL <br /> WARNING;FAILURE To SECU.RE WORKERS'COMPENSATION COVERAGE iS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIi_ 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 /> -� AUTI•IQRiz. TiON,FORi 17HER THAN C-57 SIGNING PERMIT APPLICATION <br /> {signata!re of C-57 licensed authorized representtitive), <br /> horoby authorize(print name) to sign this San Joaquin County Well 8, Boring Permit <br /> I' Application on my behalf. I understand this authorization is valid for onQ year acrd is limited to the Werk <br /> 1 plan dated on the front page of this anpllewion. <br /> EHORD-01 oM8110 <br /> weu.POVAITAPP <br />