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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL, <br /> JOB ADDRESS: G Gr'J 11,111 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 Cal ifornia Business and Professions Code and my license is in full force and effect, <br /> License #: 7/061 7C xp Date: -1- 'Yt <br /> Date: 4 - Contractor: L ✓� ���/. ���'l/,h�_ <br /> Signature! t <br /> ��t`iLIkAlt C Title: YL <br /> Print Narne: ilk\:'._w� 11�r <br /> It I.. <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 self-insure for workers' compensation, as <br /> provided forSection 3700 of the Labor Code, far 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 /> Carr7erti - et. du " Policy Number: �;C �j <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 Catifomia, <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: Signature: 'r. • .� <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SMALL SUBJECT AN F-MPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION. INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES A5 PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I (signature of G-57 licensed authorized representative). <br /> hereby autho " (print name) �agr,Gt1L, 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 /> erw»o, angio <br /> 1YELL PWwwT APP <br />