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San Joaquin County Environmental Health Department <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL " <br /> Well Location: Public Way on Yosemite Ave,south of 451 W.Yosemite Ave. <br /> JOB ADDRESS: Project site address: 420 W.Yosemite Avenue PERMIT SR # <br /> i. <br /> -I--- <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. j-- <br /> f <br /> License #: Exp Date: <br /> �/� <br /> Date: Contractor: <br /> Signature: i' ✓ Title: 6xen l��I� <br /> PrintName: LZ SFS <br /> WORKERS' COMPENSATION DECLARATION {--- <br /> I <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) ?_ <br /> 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' i. <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: / /CC'% Policy Number: O%O ��� `�; <br /> 4 <br /> 3 <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 provisions. ' <br /> Exp. Date: / ��f Signature: A <br /> Print Name: <br /> i <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, j <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. f <br /> , <br /> 7-7 FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> F <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) , to sign this San Joaquin County Well & Boring Permit 3 <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 /> f <br /> EHD 29-01 O5+OW12 WELL PERMIT APP <br />