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1110412010 15:19 5306620273 WEGE PAGE 07109 <br /> 01 40 5661 9 <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 11-06 ���� � PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> .Division 3 of the CaliforniaBusinessand Professions Code and my license is in full force and effect. <br /> License#: �\l]O� \ _ Exp Date: --`OVA 1 ' <br /> Date: .\\- ,�Lt _Contractor. 02) <br /> Signature: Title: <br /> Print Name: d ckC\ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of pedury 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 /> prnvidpd fnr by SPrtinn 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 1 have and will maintain workers' wiripensalion 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: Policy Number: Q Q °J,- �L_;F, <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' \D - nN j Signature: Q�&Y�r 10w. <br /> Print Name <br /> WARNING-FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> GRIWNAL PENALTIES AND GIVIL riHES UP TO*100,000, IN ADDITION TO T►1e COST OF 00I101PENaATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LAI3OR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby autho 'ze(print name)Ce°�` WJM& -, to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorizaWn Is valid for one year and is limited to the work <br /> pian dated on the front page of this application. <br /> EHD 24-01 07128110 WELL PERNIrr APP <br />