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EHD 20-01 07/20110 WELL PERmrrAAP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _t t11 .N `Q?Z C. 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#: y S°f 7 U Exp Date: gl3 o G t Z <br /> Date: 2.121, 112 Contractor: G L V, (C-r/7�C 4g-Soc . .T <br /> Signature; —A--( � Title: <br /> Print Name: wl�� <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (check one) <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. STATS � ;1 Policy Number: , 0)T Z01 b " ZO 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, Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALT_SUBJECT AN EMPLOYER TO <br /> CMINAL PENALTIES AND CIVIL FINES UP TO$100,000.IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 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) J�� h (il� (.Ec-tt to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. t understand this authorization <br /> is valid for one year and Is limited to the work plan dated on the front page of this application. <br /> E D28 1 MOM WELLPERMITAPP <br />