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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �a6vy U `-' 1 PERMIT SR# <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 licen`s is in fu I force and effect. <br /> lior'10License#: IJV �Q Exp Date: L'l D <br /> Date: I —I ontractor: V� <br /> Signature; Title: <br /> Print Name: <br /> WORKERS'COM SATION DECLARATION <br /> 1 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 /> 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 /> compensa"insurance ca 'er and poI'C numbers are: <br /> Carrier. , i� i Poiicy ivumber: L� �c✓'L1- <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' pensation law f Callfom(a, <br /> and agree that if I should become subject to workers'compensat'on p )Vision' "f Se tion 3700 of <br /> the Labor Code, I shall forthwith comply with those provi ions <br /> Exp. Date: I Signature: �, <br /> Print Name: ✓ � I <br /> WARNING:FAILURE To SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUB CT 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 DAMS AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A H ZATION SOOTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> (�signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) l [�l'd'sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 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 /> EHO 29-01 M199112 WELL FEFMT APP <br />