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San Joaquin County Environmental Health 11opar+ment <br /> WELL & BORING PERMIT APPLICATION SUP DI.EMENTAL <br /> JOB ADDRESS: F E:FUIT SR # <br /> LICENSED CONTRACTORS DECLA R4 TION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 icon mencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Iic :!nSE! is in full force and effect. <br /> License #: _ 1=xp Date: . J_\�.w\` 12_0\L— <br /> Date: Contractor: <br /> Signature: i'' Title: <br /> Print Name: c __. <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratic,rls ((-heck one) <br /> I have and will maintain a certificate of consent to self-ir :u-e for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the pe `o-mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, 3; r Squired by Section 3700 of the <br /> Labor Code, for the performance of the work for which Ilii:: Kermit is issued. My workers' <br /> compensation insurance carrier and policy numbe-s are: <br /> Carrier: _-70- 2,p Policy Null-bar <br /> I certify that in the performance of the work for which this pE,rrrit is issued, I shall not employ any <br /> person in any manner so as to become subject to the wore, :rs' compensation law of California, <br /> and agree that if I should become subject to workers' compE -sat Dn provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with thOSE: provision!: <br /> Exp. Date: 2—� — , `-C Signature: 000 <br /> Print Name:. <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLA" :UI.,,�.ND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, I1'1 ADDITION 1,: 1 H1: COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706(:I:1 HI: LABOR CODE. <br /> AUTHORIZATION FOR R THAN C-57 SIGNING; PERMIT APPLICATION <br /> I, ! (signature of C-5,' lige ised authorized representative), <br /> hereby authoriz (print name) , to sign this San ,laj gi0n County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid f: • onI! year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />