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San Joaquin County Environmental Health Department ` <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 531 W.Yosemite Avenue PERMIT SR # <br /> Project site address: 420 W.Yosemite Avenue <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 /> Licenser: �5���� SIGN HERE) Exp Date: <br /> Date: / l Contractor: �/PriG <br /> Signature: Title: ���CY�10/� /7?z:;)xn�� <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION - <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> - <br /> 1 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 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: 1 <br /> Carrier 9CCO/ 1)166,)0/6? 2/f 0OPolicy 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 provisioqs. <br /> Exp. Date: !� 3/ f Signature: # <br /> SlGNHERE <br /> Print Name: c /fir✓ /`lra/��/— <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL 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 /> RIZAT FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, GdZ <br /> SIGN HERE (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) , 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 f <br /> plan dated on the front page of this application. <br /> e <br /> E 21 r, WELL PERMIT APF(� <br /> f <br /> i <br /> f <br />