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E <br /> I <br /> I <br /> E <br /> E EHD 29-01 07/20110 WELL PERMIT APP <br /> i San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> i <br /> r <br /> JOB ADDRESS: W Church Street and S San,Tose St.Stockton,CA 95203 PERMIT SR# <br /> f <br /> I LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of <br /> I Division 3 of the Business and Professions Code and my license is in full forceandeffect. <br /> License#: G'� /r� Exp Date: <br /> I Date: I Z Contractor: C�d�sc� t!/i • �>//�� <br /> Signature: Title: O elegy '/�O/'s Ma"7ee=6 � <br /> -7 3 <br /> Print Name: <br /> ( <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> i <br /> } <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> "1 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 /> Xpermit 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: ,�// r L <br /> Carrier: Policy Number: �}/fG(/0 67 <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, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: Al -Signature: < �- <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORK&RS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND C(/IL FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S-FEES;AND"DlfftGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> T ZATI FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 29-D1 07120110 WELL PERMIT APP <br />