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i <br /> i <br /> EHD 2UI 07120flo WELL PERMITAPP <br /> San Joaquin County Environmental Health Department <br /> WELL BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 25 9� 6 CUUMMy Gbua 13LVO PERMIT SR #_ <br />:I I rO64: lv ;Uj CA g6"2oq <br /> LICENSED CONTRACTORS DECLARATION (LCD ) <br /> hereby affirm that I .am licensed under the provisions_ of Chapter 9 (commencitig with Section 7000) of <br /> Division 3 of the��B//uslhess and Professions Code and my license is in full force and ef'fe/ct. <br /> License #,m T� s�/ S Exp Date: V / I '7 <br /> Date: _ % 2 Contractor: . �i <br /> Signature: Tifle;- <br /> i <br /> Print Name: <br /> WORKERS' CIPMPENSATION DECLARATION. <br /> I hereby affirm under penalty of perjuryone of thefollowing declarations (check one) <br /> I <br /> _ I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> provided for by Section 970'o of the labor Code, for the performance of the work for whiob this <br /> permit is Issued., <br /> Ll have and will malntain workers' compensation lneurenoe,. as required by Section 3700 ofthe <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 /> Carriers, Ay /3 Policy Number: - - A / &&D O1 d q1 0 d i <br /> I certify thaf in the performance of the work foe Whioh 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 , and <br /> agree that if should become subject to workers' compensation provisions of Section"3700 of <br /> Labor Code, F shall forthwith comply with those provl ' ns <br /> ExP. .Date:_ a Signature: C <br /> I Print Name: , h'Cthtf P u <br /> f wARNINO;FAILURE TO SECURE WORKERS' COMPENSATION COVERAGEIS UNLAWFUL, AND SHALL SUBJECTAN EMPLGYER TO <br /> CRIMINAL PENXA T 06 AND CIVIL FINES UP TO S10g000,IN ADDITION TO TUE COST OF COMPENSATION, INTEREST, <br /> ATTORNRr$ FRts.ANp DAMAGESAs PICOVJDEp FQRIN$ECTION 3MOF THE:LABOR CODES - <br /> - - - - - <br /> AUTHORIZATI N. FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i, JL7P _ (signature of CPSY licensed authorized representatjvej, <br /> hereby auth ze (priot name). Lf1pfi�{� ;$ fL A to . <br /> sign this San Joaquin;County Wall & Boring :PermitApplii:afion on:ray behal€_ I mderstan&this.authorizat_tonF . - <br /> I. - is valid for one year and is Iiinited to -the work plan dated, on the froxt page of fti[s application. . : - . - <br /> - EM029-0f0712Uf10 - - - ' - --.W,EJI.PE(tMR'APP - <br />