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N <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS : 16 6 C00 ��� C� c PERMIT SR # <br /> I <br /> LICENSED CONTRACTORS DECLARATION ( LCD ) <br /> i <br /> 1 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 /> i <br /> i, <br /> License #: kDUA�t Exp Date: <br /> Date: � t�!D Contractor: A A>y i <br /> Signature: i 1 - r i- Title : V 1{ YIA <br /> PrintName: 0hV-VN IVIA i 1, <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 /> 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 /> Carrier:�� nPolicy Number: <br /> (and � <br /> I certifykiW �o <br /> for which 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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions . j <br /> Exp. Date : � j � � c {} Signature: 'n <br /> Print Name: ` m G <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,0005 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 /> AUTHORIZATION FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> 11 ',r fi' , \L0 _ (signature of C-57 licensed authorized representative), <br /> � V�o sign this San Joaquin County Well & Boring Permit <br /> hereby authoHze (print name) { 4�3 <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 /> EHD n4)1 05MII15 WELL PERMIT APP <br />