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r San Joaquin County Environmental Health Department <br /> .. C 4. <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I - <br /> 0 <br /> I <br /> JOB ADDRESS: PERMIT SR# <br /> I <br /> ( LICENSED CONTRACTORS DECLARATION (LCD) <br /> I 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 /> ... ... ..::. <br /> License#: CS 7 Exp Date: <br /> Date: E7 ,! <br /> Contractor. <br /> / r - <br /> I 7 <br /> Signature: Title:��'� O/� <br /> ;I <br /> Print Name: <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) !I <br /> I 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. i <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: f� <br /> Policy Number: /�t✓t%ti�lt� //G�/_: <br /> I certify that in the performance of the work for which this permit is issued, 1 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. <br /> Exp. Date: <br /> Signature: <br /> Print Name: t-�//��� l! � <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TQ.,-, I- <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 /> T RI TION.FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i <br /> (signature of C-57 licensed authorized renresentativ'M <br /> here authorize / <br /> (print name} �-s;�.. },M V to sign this San Joaquin County Well 8..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. rr: <br /> EHD 20.01 0SIagg2 .. <br /> YJELL PEPmr.APR j <br /> II; <br /> '•4 <br />