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END 20-01 07120110 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _4 1; is .N.►# r_ ez L-scA tc_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#: c y S°J 7 U Exp Date: `313 O l t Z <br /> Date: Z- [z?, I II /) Contractor: En v. Cc n��c 4sSyc <br /> Signature; _ Title: / 5 <br /> PrintName: �ti WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (check ane) <br /> I have and will maintain a certificate of consent to self4nsure 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier. >TATF E ✓nr1 Policy Number: 1 Y7 Z016 — Zo I I <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 Code, I shall forthwith comply with those provisions. <br /> Exp. Date' NAS_ Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 51100,000,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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />