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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS: 429W.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 's in full force and effect. --h <br /> _ 1 <br /> License #: '7/- <br /> 7G�� � Exp Date: i. <br /> G / �;� <br /> Date: <br /> Contractor: <br /> Signature: Title: <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> c I <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 /> t <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: Policy Number:/e�/-Ce rt)r <br /> 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, <br /> and agree that if I should become subject to workers' compensatio provisions of Section 3700 of <br /> the Labor Code, I sh II forthwith comply with those provisio s. <br /> Exp. Date: Signature: <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 /> T IZA FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i <br /> (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 /> 'r <br /> F <br /> EYD 25-01 05P)4112 WELL PERMIT APP i <br /> }1 <br /> 1 <br /> I <br />