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San Joaquin County Environmental Health Department <br /> WELL &BORING PERMIT APPLICATION %i-Ji"PLEMENTAL <br /> JOB ADDRESS: 11115 Might Nil. ag,a, sscekton, CA PERMIT SR# <br /> LICENSED CONTRACTORS DECIJ FATION (LCD} <br /> I hereby affirm that I am licensed under the provisions of Chapter S, (corimeneing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my lit.fns;l is in full force and effect. <br /> License#: Exp` Date: .i!t�i 3o�,11 2-0 1 u <br /> Date: contractor:- �1�. 1 L.' L-I[10)2 ffun - <br /> Signature:�/� Title: Yt 1 <br /> r' <br /> Print Name:/ <br /> WORKERS' COMPENSATION DECLAI;:ATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (,,,,heck one) <br /> I have and will maintain a certificate of consenl to self-im.ira for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the pei"formance of the work for which this <br /> permit is issued. <br /> 41 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 t lis permit is issued. My workers' <br /> compensation insurance carrier 4and policy numbers are: <br /> Carrler:an,} t_ T-,_ L41 Policy Nurrher <br /> I certify that in the performance of the work for which this perniii is issued, I shall not employ any <br /> person in any manner so as to become subject to the workl;'scompensation law of California, <br /> and agree that if I should become subject to workers' comper.:a lo-i provisions of Section 3700 of <br /> the Labor Code, i shall forthwith comply with those provisions. <br /> Exp- 1211'2.013 Signature: <br /> Print Name:_ <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE:IS UNLAWFI:1., 4K:)SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO 7H'E +::OST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THIS LABOR CODE. <br /> AUT F HER THAN C-57 SIGNING FIE R MIT APPLICATION <br /> (signature of C-57 '�xn;led authorized representative), <br /> h eby orlzmp,int name D°niet 'AL!....1. <br /> �� , to sign this San Jc,;,q jin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization Is valid for ani wear and is limited to the work <br /> plan dated on the front page of this application. <br /> Enozeai ua 12 <br /> WELL PERMI?"P <br />