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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: � 1� �u�� I I �,�L , J�Z�.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 license is in full force and effect. <br /> License#: GS 7 Y-�4� Exp Date: d'3/ /c <br /> Date: / Contractor; <br /> Signature: - Title: Oaer-a 6QC/ ///o/r3v -Qr <br /> Print Name: fs PrC,(,,077&o0'­ <br /> WORKERS' <br /> COMPENSATION DECLARATION <br /> 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 /> compensationi�nsurance carrier and policy numbers are: <br /> Carrier: �KPolicy Number: &/C�vo/o AM/ <br /> 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: bz; A-e—, Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT 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 DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> 2x- <br /> (signature <br /> R TION FOR OTHER THAN C-67 SIGNING PERMIT APPLICATION <br /> i, �Z--- of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Baring 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 /> EHD 29-01 WW112 WELL PERMIT APP <br />