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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 500 East Louise Ave., Lathrop, CA PERMIT SR# <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 Bus' ess and Professions Code and my license 's in full rce and effect. <br /> t (� <br /> License#: � E Le <br /> \� Date: t � <br /> Date: Z ontr ctor: V ) ,IWAli( <br /> Signature: f� Iy Title: <br /> t <br /> Print Name: <br /> WORKERS' COMPE S ION DECLARATION <br /> I 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 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 /> compeion insur Ce carne° <br /> ns2tand policy numbers are: /� ll <br /> Carrier Policy Number: �1 <br /> I certify that in the <br /> —p�je'–rf�forrmance of the work for which this permit is issued, I hall hot empllay,any <br /> person in any manner so as to become subject to the workers' compensat-on layyv of Califor ia, <br /> and agree that if I should become subject to workers' compensati provisos of 6action'370of <br /> the Lab Cod , 1 shall forthwith comply with those proy'sic r <br /> Exp. Date: Signature: / <br /> Print Name: Y 1 <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EM LOYER TO <br /> CRIMINALPENAC71 S AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORN . S FEES,AD DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> �AUTH RIZATI FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, \ (signature of C-57 licensed authorized representative), <br /> hereby aut rize(p int nam )�� o 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 /> EHE 29-01 05109A2 WELL PERMIT APP <br />