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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS; 1 3� � SOU� S�ti `tOCI S} PERMIT SR# <br /> CA <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 1 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. <br /> License#: 5 �Q Exp Date: <br /> Date: Contractor. <br /> Signature: �-�.-r Title: <br /> Print Name:_%! <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> Yl 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 /> 1 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: <br /> �.� Policy Number: �r�C� C?�� Y-�/� <br /> 1 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 1 should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those pr ons. <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.ANN dAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 11 . 9-141, ..- (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) a 0. f A , 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 /> END 2S-01 05!09/12 WELL PERMIT APP <br />