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P. a <br /> San Joaquin County Environmental Health Department <br /> 2WELL & BORING PERMIT APPLI ATION SUPPLEMENTAL <br /> JOB ADDRESS: ZS3 / PERMIT SR# 6a� <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 Exp <br /> Date:: S�3//? Z <br /> Date: (e I` It a Contractor. <br /> Signature: C Title: <br /> Print Name: 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 /> yI 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 /> Carrier:_1i,Jru6T /'r�/Ea�.s.�c,c G• Policy Number: g57wriTi/29S <br /> I certify that in the performance of the work for which this permit is issued, 1 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' com nsation provisions of coon 3700 of <br /> the Labor Code, I shall forthwith comply with those provisi. / <br /> Exp. Date: —VZ/boi L Signature: <br /> Print Name: #Wf <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 ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> &UTHQRI /1 P ER THAN C-57 SIGNING PERMIT APPLICATION <br /> r <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)nq,�i[ </'(1,4,LW-/A , 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 /> IJ iO:'e-0, <br /> 1117A 1n WELL PERT APP <br />