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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMfF APPLICATION SUPPLEME14TAL <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 Cat ifornla Business and Professions Code and my license is in full force and effect. <br /> License 9: Cf7- 7100 75? E xp Date: 1-31-lt L.._ <br /> Date: --5- ---1�) - Contractor: �/�/G tcc*ac� l��•'l�h <br /> t <br /> Signature:i�j4acrn� >13� �s'�- Title: l 'Q5; C1�t1 <br /> Print Narne: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check ane) <br /> I have and will maintain a certificata of consent to self-insure for workers' compensation, as <br /> provided for by Section 3700 of the tabor 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 Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier �_ Policy Number; F- 1'' <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 provisions. <br /> Exp. Date: \C)-J- Q Signature: Q401A,%Qrsa � - <br /> Print Name 1-,)cur <br /> WAPmuGG FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 15 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000, IN AUDIMN TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES.AND DAMAGES AS PROVIDED FOR IN SEcnoN 3706 OF THE LABOR CODE. <br /> AUT)iORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 7 c (signature of C-57 licensed authorized representative), <br /> hereby authors (print name) �E C nvu , 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,timited to the work <br /> plan dated on the front page of this application. <br /> D02-"i mftlo weUrEAMTAPP <br />