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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL '" <br /> JOB ADDRESS: 531 VV.Yosemite Avenue PERMIT SR # <br /> Project site address: 420 W.Yosemite Avenue <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> —-x <br /> c` <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of 1 <br /> Division 3 of the California Business and Professions Code and my licens is in full force and effect. ---� <br /> License #: � Exp Date: <br /> Date: J Contractor: <br /> 1 t: - <br /> Signature: Title: <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION _ a <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> ! _ t <br /> 1 have and will maintain a certificate of consent to self-insure for workers' compensation, as s <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 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 iinnssurance c rrier and policy numbers are: <br /> Carrier: //C�/� Policy Number:&/-C- ! - <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 provisions. f <br /> Exp. Dated� / 2 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 5100,000, 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 /> fi. <br /> ON OTHER THAN C-57 SIGNING PERMIT APPLICATION 6. <br /> I• (signature of C-57 licensed authorized representative), l <br /> hereby authorize (print name) , to sign this San Joaquin County Well & Boring Permit f <br /> I <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 /> EHO 29-01 0`X9112 WELL PERMIT APd <br /> i <br /> E <br />