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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: V l 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 Cade and my licensq is in full force and effect. <br /> License#: J lJ t/LA Ex Date: �l <br /> Date: I —I ontractor: <br /> Signature: (-1 ) Title: <br /> Print Name: �( 1'( <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 /> 1 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 polic numbers are: <br /> Carrier. ), � i Policy Number: r- <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, <br /> and agree that if I should become subject to workers'compensat•on p ovisions 'f Se tion 3700 of <br /> the Labor Code, I shall forthwith comply with those provi ions <br /> Exp. Date: � I Signature: <br /> 1 )� <br /> Print Name: ✓ i I Rry <br /> / )' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUR 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 DAY:S AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A H ZASION FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> f (��sig��nature of C <br /> II -57 licensed authorized representative), <br /> hereby authorize(print name) IEE- I (qV 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 /> plan dated on the front page of this application. <br /> EH0 29-01 05109/12 W ELS FERMIT MP <br />