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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS 20g7-l710.5 �j��4t�c;n� Ad, Trim, gi5yi I PERMIT SR 9 <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 tth�e Califo?rnia Business and Professions Code and my license!,s in II force and effect. <br /> License#: 1 I 6 ? <br /> Exp Date: <br /> Date: r0 ( Contactor: <br /> Signature: Title: l <br /> Print Name:_ / Qh-- <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> _ i nave and will maintain a certificate of consent to self-insure for workers` compensation, as <br /> provided for by Section 3700 of tate 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 ano policy numbers are: <br /> i <br /> Cartier: _ Policy Number: !U r <br /> I cerlify 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 pr itTs_�)Section 3700 of <br /> theLa//b��or ode shall forthwith comply with those provisions. / <br /> Exp,Date: (O �G U <br /> Sig <br /> Print Name� � 7 _ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPEN8ATION COVERAGE IS UNLAWFUL,AND SMALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,006, IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SEC'nON 3706 OF THE LABOR CODE. <br /> AUT R ___ _ C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) wrt StiCAL1, to sign 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 /> ` pion dated an the front page of this application. <br /> E'D 3v-0: JSVG1; <br /> 'vyf!.l.PFRM'T APP <br />