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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR 9 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter g (commencing with Section 7000) of <br /> Division 3 of the California Business and Profossic=ns Code and my licanse is in full force and effect. <br /> License M. CF?— 7/Dei (/ _E xU Date: 'I <br /> Date: (? 1 '� _ Contractor., c��c <br /> Signature: A Title: �� G`.� ��•� (\ _ <br /> Print Name: Co—l .�'�:c� i ,;c..c :c-,\t,� <br /> ry <br /> WORKERS, COIMPERSATION DECLARATION <br /> hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> have and will maintain a certificate of consent to self-insure for Workers' compensation, as <br /> provided for by Section 3700 of the Labor Corte, for the pprformance of the work for which this <br /> permit is issued. <br /> 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 /> Carrler , ^ 4.-7 t;1'' � Policy Number: ` <br /> 1 certify that in the performance of the work for which this permit is issued, I shalt not employ any <br /> person in any manner-so as to beccrne subject to the wortcers' compensation law.of Californla, <br /> and agree that if I should b�-conie subject to workers' corrnpensatfon provisions of Section 3700+ of <br /> the Labor Code, I shall forthwith comply,with those provisio:ls. <br /> Exp. ❑ate: <br /> Print Hams.i CS' ,(ki c I•';r'Xi(��U 1-,4 <br /> caved <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVEiPASF IS 4L fXVF171;AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIViL FIRE-i UP TO S100,00D, IN ADDITION TO THE COST OF COMPENSATION, INTEREST. <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 'AUT)iORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION � <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorl (print name) CC��c �arlycY.2^, to slgn 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 /> WELL ER1?.T APP <br />