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JA* w ; fj � <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ()1Jl) w� 1,�(�1 — aJIT PERMIT SR# <br /> LICENSED CONTRACTORS ALARATION (LCD <br /> ) <br /> I hereby affum that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of thhe+ Ca4omia Business and Professions Code and my license is in full force and effect. <br /> License#: Exp Date: <br /> Date: Contractor: <br /> Signature: Title: UV_01" O,�aaFY <br /> Print Name: /"/-u1715,:/ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby&t- y of perjury one of the following declarations: (check one) <br /> _xI raw o www oo�4 maintain a certificate of consent to self-insure for workers' compensation, as <br /> ovided tx 6on 3700 of the Labor Code, for the .performance of the work for which this <br /> I ►v++o wxi a& Asintain workers' compensation insurance, as required by Section 3700 of the <br /> Lem+ :txla; ^-iw me performance of the work for which this permit Is Issued. My workers' <br /> ct,r •r� <br /> -. <br /> , . ,rance carrier and policy numbers are: �/ <br /> Carrier/i,y/__0' Policy Number. /Vlnl/0101"��P/ <br /> performance of the work for which this permit Is issued, I shall not employ any J <br /> ps^xrr rt st-<. miner so as to become subject to the workers' compensation law of California, <br /> arra atlee raw t should become subject to workers'compensation provisions of Section 3700 of <br /> Vw Labor Cr+*. shall forthwith comply with those provisions. <br /> Ex . Date P Signature: -� <br /> Print Name: C�1/'6C <br /> WARNING:FA0_LJgl TO f WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> C A%W%+4L PGbv,,INS AND CIVIL FINES UP TO:100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST,_ <br /> ATTOAMEYS FVJ,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> T ZA FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, �'�� (signature of C-57 licensed authorized representative), k <br /> hereby authorize(prin!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 /> pian dated on the front page of this application. <br /> :Floe'.-Oi 05/0112 WELL PERMIT AP11 <br /> r, <br />