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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ��pkGt oR C 4 <br /> JOB ADDRESS: � o,g� r t)t 5 PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD), <br /> 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 #: _ 1 1 Q Q-1 q Exp Date: —1-3L-\ 5 <br /> Date: _J5 -a U- l� Contractor: <br /> Signature: kZ 10,e4, 8 Title:2,a 12 n; 6.gn_t <br /> Print Name: 1� ac�a t.��n ►,�a S`c1 <br /> WORKERS' COMPENSATION 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 /> compensation insurance carrier and policy numbers are: <br /> Carrier. .u)N r-r.'MNg-Z Rp *,,-C;eaOr F Policy Number:t„')Q FAO 0L)_()()e.A gfj <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, <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:_ Signature: .Q! \e�t�s����► rl <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> ISo )IAJS �J a,,, ,A (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) I-�i '-, Ah 4" to 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 /> EHD 2941 G&W12 WELL PERMrt APP <br />