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Z <br /> k <br /> San Joaquin County Environmental Health Department <br /> 3 WELL & BORING PERMIT APPLICATION SUPPLEMENTAL :I' <br /> x JOB ADDRESS: �GC7Sv�l;U 1�0; e, PERMIT SR # <br /> I - , <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> k <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#: `fes��(,1 Exp Date: <br /> Date: f/% 113 Contractor.- <br /> Signature: <br /> ontractor:Signature: � .r' / 2 _ Title: C ,L&G <br /> jPrint Name: <br /> 1 <br /> WORKERS' COMPENSATION DECLARATION <br /> I <br /> 's <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i <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 /> i <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> I 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 /> c Carrier: r G�0'CY Policy Number: (74//G(i <br /> i <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 /> j the Labor Code, I shall forthwith comply with those provisions. <br /> i <br /> I <br /> Exp. Date: �5��� /,� Signature: <br /> f <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 $900,000, 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 /> RIZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �UT <br /> si9 nature of C-57 licensed authorized representative), <br /> hereby authorize(print name)f;U?r+ ?,)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 /> EH02M1 05/03/12 WELL PERVIT APP <br />