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7 <br /> EHD 29-01 07/20!10 WELL PERMIT APP <br /> i <br /> San Joaquin County Environmental Health Department <br /> 4 WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> k <br /> JOB ADDRESS: a05� JOu <br /> arGr� C. 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 Business and Professions Code and my license is in full force and effect. <br /> License#: Exp Date: <br /> Date: �� Contractor: <br /> Signature: -�_�_ Title: <br /> Print Name: <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 /> I 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),,��'tiJforo� Policy <br /> E <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 become subject to the workers' compensation law of California, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor e, I shall forthwith comply with those provisions. <br /> i Ex Date: <br /> e Co1�///Z <br /> P� Signature: //��' <br /> Print Name:(-.�'//�<f <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000,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 /> O TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, y� ,� (signature of C-57 Ii c nfsed authorized representative), <br /> i hereby authorize(print name) 5C1IJI n r(( <br /> ,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 /> EHD 29.01 07/20/10 <br /> WELL PERMIT APP <br /> I <br />