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EHD 2MI 07/20110 WELLPERFAITAPP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1050 tE -D1At--I01rz:> PERMIT SIR# <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 Business and Professions Code and my license is in full force and effect. <br /> License#: 75S cp OL} Exp Date: ((D- ':�>1 - Z-n l7_ <br /> Date: (60-t -20 L Contractor: A-T�-- aiZ-0LJ-P`�VtC65 tAJC . <br /> Signature: t Title:_ �uat tFYt t c7 �n(A W!DuA t, <br /> Print Name: �FFREtY e• Pl�tt�y <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 /> K 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: <br /> Cartier: )At-(41ZA1JCe6n�rl.4NY41= -Tst5 Policy Number: 9'415(3-7 <br /> vF -PA, <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 became subject to the workers' compensation law of California, and <br /> agree that if[should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature: CQ'.� <br /> Print Name: ZTE,AP-1 1--I& 44 oNISF,Y <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE ISUNLAWFUL,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 /> THQRt&,9oNr OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 71 <br /> ` (signature of C-57 licensed authorized representative), <br /> he authorize(print name) ,to <br /> sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated,on the front page of this application. <br /> EHO 28-01 07RW10 WELL PERMIT APP <br />