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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 /> License T: < srGv!T Exp Date: <br /> --I <br /> Date: / / Contractor: ��riri <br /> Signature: Title: r 2*71?zano � <br /> Print Name:_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> l� 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 <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/27CCO Y /2/6S0/0 W/00PoIIcy Number: �GGUG/G <br /> r <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 I <br /> the Labor Code, I shall forthwith comply with those provisio . <br /> a�R,Exp. Date: ( 3/ Signature: A SIGN HERE <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 $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 , ��� srGNHERE (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 <br /> plan dated on the front page of this application. <br /> E�:D 2w.7 Ofdu^9 i2 WELL PERMIT APF t <br /> E <br /> I <br />