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' , 11/0412010 15:19 53066202.7q WEGE PAGE 03109 <br /> San Joaquin County Environmental Health DSpartmont <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> .JOB ADDREss: / 7Ca ��� C41 g�a f7644P ERMIT SR# d61 Z <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 /> LiC9nse#: Exp Date: <br /> Date: \\ -\O Contractor: ` <br /> Signature';�j9mx mt&, <br /> Print Name_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 worts for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are, <br /> Carrier: Policy Number: W\LA 35q q -amu l0 <br /> I certify that in the perrormance 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 37UU of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: \tD -\ - L Signature: <br /> Print Name.�4(ljp,l g, 'F 1-000 A-L�G1x--A <br /> IJ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE rS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> C1i rMNAL PENALTIES AND GWIL FINES UP TO$100,000, IN ADDITION TO TNR COST VP CaMIPC"ATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, d •(signature of C-57 licensed authorized representative), <br /> hereby autho a(print name)C&MM Q r0u,2r,-,T-, to sign this San .Joaquin County Well s 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 /> erre 2"i 07"0 WEii PERMIT APP <br />