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1- <br /> San Joaquin County Environmental Health Department 'T:`'" <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: W� PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATIONLCD <br /> t ) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of thee^ California Business and Professions Code and my license is in full force and effect. <br /> License#: G-� �c -f�� Exp Date: if _ <br /> Date: _hContractor: <br /> Signature: .—j- Title, �„ �GJ�/G� pAiC> �— <br /> Print Name: <br /> waftUAW COMPENSATION DECLARATION <br /> �I <br /> I hereby affirm under perallto * - *.m of the following declarations: (check one) <br /> have and will rywwwaa s rate of consent to self-insure for workers' compensation, as <br /> rovided for by iftir x rza Labor Code, for the ,performance of the work for which this <br /> permit Is issued. <br /> I have and will neral + wLp4mm compensation insurance, as required by Section 3700 of the <br /> Labor Code, for 9w of the work for which this permit Is issued. Ivry workers' <br /> compensation Insuompw e nwf policy numbers are: �/ <br /> Carrier: �C�' Policy Number. �e t�� <br /> I certify that in tho ; + r ; the work for which this permit is issued, I shall riot employ any J <br /> person in any Lna~- to so - 4wcome subject to the workers' compensation law of California, <br /> and agree that If I •hmx ban*~_ subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code, I s tlr ttrr4swam -xxnply with those provisions. <br /> Exp. Date:E �/� Signature: <br /> Print <br /> WARNING:FAILURE TO SECURE W011111GERT VNAP 4SATION COVERAGE IS UNLAWFUL,AND SHALL.SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AM Crft *-008 UP TO$100,000, 1N ADDITION TO THE COST OF COMPENSATION, INTEREST,_ <br /> ATTORNEY'S FEES,AND DANAM!-$PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> aT ZA FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized: representative), <br /> heeeby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understarid this authorization is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> er;n z�•nt as;csnz <br /> VJ£lL PEF.1d1T PPP <br /> i' <br />