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Jul 04 04 10:34p Richard Tyler 5405 2238 p.t <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR I$ <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 /> -11 <br /> License# 615-176 Exp Date: I , <br /> Date: ¢! bl i S Contractor: !NU. e o- 7-2nt A Sfo c , <br /> Signature: Title: <br /> Print Name: yl—r"t---T t 1� <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 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 wilt 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: 19 -7 20 9,: — Z b 1 S <br /> Carrier: 57`4 f e �Ur 7 y Policy Number: e;5� 4'2 <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 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: S1 3 /C( Signature: . �� <br /> Print Name: h lex <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADOmON TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SE"ON 3700 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, rl CJM Tj 6i✓ (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) CHAD $ECII to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this authorization is valid for one year and is limited to the work <br /> plan dated an the front page of this application. <br /> EO39A, 9S -M2 <br />