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I <br /> gi <br /> I San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> i <br /> {{° JOB ADDRESS: PERMIT SR # <br /> I <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 Business and Professions Code and my license /is in full force and effect. <br /> License #: ' hT� I (D � Exp Date: I <br /> Date: o� I v Contractor: <br /> Signature: `— -- Title: UW <br /> f e <br /> Print Name: 1` 1 <br /> i <br /> WORKERS' COMPENSATION DECLARATION I <br /> `s <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 /> I <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:.A D t�,) Policy Number: R / [✓' Gt ) D / Q y/3 d Z <br /> 1 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 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 <br /> /forthwith comply with those provisi <br /> Exp. Date: O / I / y Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,0003 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 /> IUITHO� ;IZGeATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of CZ7 licensed authorized representative), <br /> hereby aut rize (print name) T)CLrllO Vi I IPi7 tC 4f&srign 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 /> EHO N2 l 0510112 WELL PERMIT APP j <br />