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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2 315 N. El Dorado St, Stkn, CA 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 California Business and Professions Code and my licens is in f II force and effect. <br /> License#* C57-720904 <br /> Exp Date: tA <br /> Date: r I Contractor: Vow Drilling <br /> Signature: ` Title: <br /> troin <br /> Print Name: Karli <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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 /> compensa ' insuranc arrier and policy numbers are: <br /> Carrier. Policy Number: <br /> I certify that in the performance of the work for which this permit is issue hall not emplo any <br /> person in any manner so as to become subject to the workers' com ensati n law of C Ifor , <br /> and agree that if I should become subject to workers' compensation ovisio sof Secti 3700 f <br /> the Labor lode, I hall forthwith comply with those pro ' ions. <br /> Exp. Date: Signature: �411D [/� - <br /> `-�Print Name: 4<h1 �()� <br /> WARNING: FAITO CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN OYER TO <br /> C INAL PE LT <br /> IES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> A TORNEY'S F ES,AND AMA ES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> / <br /> ORIZATION FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I <br /> 1, (signature of C-57 licensed authorized representative), <br /> Raynold Kablanow <br /> hereby authQonehalf. <br /> t nam , to sign this San Joaquin County Well & Boring Permit <br /> Application 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 29-01 05/09/12 WELL PERMIT APP <br />