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Jul 04'0410:34P/1 t Ri^d Tyler � 541 5 2238 p.1 <br /> i <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR N <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# 6 0} ��} 7l� Exp Dafe: Cf <br /> Date: �7�'b l f S Contractor: L/✓L. e u . rm,L A Sf o c , <br /> Signature: Title: <br /> G 7� j� <br /> i <br /> Print Name: r�- <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 work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: t 9 1 20 q6 — Z t� is <br /> Carrier: 5] q (L +�v.N() Policy Number: e;5:9 4V!;7-2 <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 ff 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: S-15116 Signature: <br /> Print Name: � c,2- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO SI00,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> _AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I' M! iylE: Z (signature of C-57 licensed authorized representative), <br /> hereby authorize,(print name) CHATlSECk/] L, 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 /> EN02401 OS W2 <br /> =LL-1UR ,..P <br />