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San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �T6 37 j '�16 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 California Business and Professions Code and my license is in full force and effect. <br /> License #: L'E?- 7/0,-17y E xp Date: -I--3\---Q <br /> Date: 5 --D Q--1—t Contractor. �'�/Gcca�crraFci/ !��•"�/ham <br /> Signature:Q _VY\41, � ���� Title: T,JICc J l ��%ILt <br /> Print Name:__ C�(1�\1,'' � A t OSx f <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 setf-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 carder and policy numbers are: <br /> Carrier F,ct\t`{\CC�-[,d �L+1c u�"5 U Policy Number: 00,Q6 to, q r3 ltd U <br /> 1 certify that in the performance of the work for which this permit is issued, 1 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: 1-'13 _ Signature: g��.4�ruti��� <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 r'E:ES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, v 1 (signature of C-57 licensed authorized representative), <br /> hereby author (print name) Canvat9-, 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 /> 0-93 29-01 Vraia sYKI.FERMT APP <br />