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EHD 29-01 07/20/1C WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 of the Business and Professions Code and my license is in full force and effect. <br /> License#: T� Exp Date: �lTl �V' 1 ID <br /> Date: . 21' <br /> 1, Contractor:_ �� WP�� .t-6(n 1 cl At <br /> Signature: �-� Title:_,dent <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> have and will maintain a certificate of consent to:elf-insure for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, fcr 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:_s�k-P h X-YA Policy Number: <br /> 1 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 tie workers' compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature,. <br /> Print Name:_ (2-c.)-a-V <br /> WARNING:FAILURE TO SECURE WORKERS,'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> 9R0 WAL.P.ENALTIES AND CIVIL 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 /> O ER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, �!✓ �� (signature of C-57 licensed authorized representative), <br /> hereby authorize print name) ,to <br /> sign this San Joaquin County Well&Boring Permit Applicatz'on on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 29-01 0720/10 <br /> WELL PERMIT APP <br />