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- w- <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> Jag ADDRESS: 2102 South California Street, Stockton, CA 95206 PERMIT SR# <br /> LICENSE® 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 /> License#: 5`) -7 0 Exp Date: <br /> Date: _. `i 1/1-1- Contractor: I A_�oc , .-dv L <br /> Signature: _ 7� J4/ Title: <br /> Print Name: <br /> WORKERS' COrriPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <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 <br /> permit is issued. <br /> r <br /> _I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br /> Labor Cade, for the performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: 5f,IT-c F0^-' Policy Number: � °� -7 �4 f <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 provisions. <br /> Exp_ Date: [� I 1 �' Signature: 7 <br /> Print Name: &,4- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOI'ER 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 /> '�'A0`E°'HbM ATI6l` FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> T- -_ <br /> €, `' (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) - ! �. /� !z,,��k 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 /> EHD 29-01 05/09/12 <br /> WELL PERM1SI7 APP <br />