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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �a6vy D l.-'"I 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 C'alliifoomiaa Business and Professions Code and my licenls 'Isin/\fu I force and effect. <br /> License#: t� J V f lOLA Exp Date: L'l v <br /> Date: I —! ontractor. UD 06 IJG' V l� <br /> Signature: (-1 `� Title: <br /> Print Name: `( <br /> kA <br /> WORKERS'COM SATION 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 /> 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 /> compensay7 Insurance ca .er and polis numbers are: <br /> f 1 <br /> Carrier. ✓i I Policy Number: I�L/Ly i 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' pensation law f California,and agree that if I should become subject to workers'compensafon p ovislons 'f Se tion 3700 of <br /> the Labor Code, I shall forthwith comply with those provi ions <br /> Exp. Date: I Signature: <br /> , <br /> Print Name: ✓ rl I r�� �' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUB 114 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 ZA510N FO OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> 1, V 1 � V (s' nature of C-57 licensed authorized representative), <br /> hereby authorize(print name) l (e L`b'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 /> EHD 27-01 05107112 WELL FERMMT APP <br />