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.SRN JC, QUIN COUNTY- WELL-PERM <br /> PL.pdf hu :(/w� <br /> P Cehd.COm/dOCS/WELL-PERMIT-APPL.pdf <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _1 3 o� \0 .&a vtPy � J <br /> � 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 offiithe <br /> --California Business and Professions Code and my license is in full force and effect. <br /> License #: Cal - j J I C� <br /> Date: ' ( a 01 EJ �Ex� - <br /> p Date: 51 - 12> <br /> Contractor: C)Ca,-O ,2 <br /> Signature: <br /> ,st <br /> Print Name: l U/ ) VUDOG�t �Al2() <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 /> 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: I iy-IF 020 tid(/ S f Y <br /> i./ 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 workers'Compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those p ovisions. <br /> Exp. Date: /0Z/ <br /> Signature: <br /> PrintName:0—on[1,Lng <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO S100,000, IN ADDITION TO THE COST OF COMPENSATION, <br /> ATTORNEY'S FEES,ANDD�DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. INTEREST, <br /> AUTHO f�ATj712F R O�THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authori a(print name)Qre <br /> to sign an <br /> Permit <br /> Application on my behalf. I understand this is authorization islvalid for oone ly aro unty and is limitedoring to he work <br /> plan dated on the front page of this application. <br /> 2of2 <br /> EHo n.01 05f1,9,12 <br /> 3/11/13 12:41 PM <br /> WELLPEeMiTAPP <br />