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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLIr:ATION SUPPLEMENTAL <br /> JOB ADDRESS : �) � ` � E" .` iV (A( I � PERMIT SR # <br /> SVC, C c <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 #: F)L- 2j� ��� =xpDate: <br /> Date: Contractor: _ _ � � � <br /> Signature: - - Title : _ <br /> Print Name: <br /> WORKERS' COMPENSATIOV DECLARATION <br /> I hereby affirm under penalty of perjury one of the followinc 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 iisurance, as required by Section 3700 of the <br /> Labor Code, for the performance of the work f x which this permit is issued . My workers' <br /> compensation insurance carrier and policy number ; are: <br /> Carrier: (' �A t TlX�lI P —1 <br /> 0At <br /> olicy Number: T�) <br /> I certify that in the performance of the work for wh ch this permit is issued, I shall not employ any <br /> person in any manner so as to become subject t ) the workers' compensation law of California, <br /> and agree that if I should become subject to worke FS' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Signature :_ , ; <br /> PrintName: _ {� 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 $700,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SE( TION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name)11,n, k NMNwagea, 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 /> plan dated on the front page of this application. <br /> EHD 2941 OMWO WELL PERMIT APP <br />