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San Joaquin County Environm ental Health Department <br /> WELL S BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 3535 Ct erotee R..d,SI.M. <br /> PERMIT SR# <br /> LICENSED CONTRACTOR; DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions o-Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Cod�and my license is in full force and effect. <br /> License#: `4A ( Exp Date: JI",1'1)\ I Lr 1\1- <br /> Date:—,\ <br /> \Date_ ,\ `� ` 1 r \'� Contractor: <br /> Signature: _ Title: <br /> Print Name: <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 /> _X I have and will maintain workers' compensation i Isurance, 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 number! are. <br /> Carrier: C j(' { l\ A d Policy Number: <br /> I certify that in the performance of the work for whi,:h this permit is issued, I shall not employ any <br /> person in any manner so as to become subject tc 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 provisions. <br /> Exp. Date: I 1 l`}2 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 A)DITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECT'ON 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) "R""""`t'` 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 /> EHD 3"1 0111111 <br /> WELL PERM!?APP <br />