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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS; PERMIT SR# <br /> LA <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that;! am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> DiViS10n 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: rJ R05 Exp Date: ,�70 tot(0 <br /> Date: Contractor: �r��� A0 , <br /> Signature: Title: ��1i�1, �.Cli <br /> Print Name:___a7/'rr <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> -,I have apt _will maintain a certificate of consent to self-insure for workers' compensation, as <br /> proked for'by Section 3700'of the'Labor Code, for the performance of the work for which this <br /> permit is issued. <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: ee9/ln l o/0 Y/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 pr ons. <br /> Exp. Date: �TSignature: ��— <br /> Print Name:� ly <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 1S 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 /> TRI PN FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) a NXV�1Y1 , 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 /> i <br /> EHD 29-01 05!09112 WELL PERMfT APP <br />