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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 032 E, %R���� 5�,c(��a�. C}!r 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 license is irk full force and effect. <br /> License#: G.S 7Exp Date: l i� 11r J <br /> Date: 7l. Contractor: <br /> Signature; ( ��,�.s�.� Title: -/ <br /> Print Name: <br /> 1"-1C'RKEPc' COMPENSATIvii 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 maintGin 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 and policy numbers are: <br /> Carrier: Polic l�uGL� y /Cl/l]OICS <br /> Number: <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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:_ / :-->/ )) <br /> (t1 _ Signature: <br /> Print Name:_���lj ��� <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CR UINAL 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 /> AU-THOR17ATfON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 4 <br /> �1�i I <br /> I, 1Z� *o ff-�_ (signature of C-57 Ilcensed authorized representative), <br /> hereby authorize(print name) T�,r�11�,��u� , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 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 OSS 112 <br /> WELL PERMFr APP <br />