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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: -1 1 Ino,g� ��n ,f a) PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> •.may•y y.,. •�t'! .�-S"�•;:,i <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 #: 1 loo--12 Exp Date: <br /> Date: Ji -a 0- 1 y Contractor: <br /> Signature: (�,cr,\CAMR) �_lJ � Title: ,ate n <br /> Print Name:_ O pR\o'kn o �. ►,inn c1�,�a S'c� <br /> J <br /> WORKERS' 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 /> _ 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. .0 urx-K Mf,x-,,c�p �,CpforgR Policy Number:l,,'IQ Rod Dp(�an% <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: \ t) - k-\`\ Signature: (� n� > 9tq ,l,.o.., c•1 <br /> Print Name: L oc1 Dicta \.>Il nAW ac' <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 /> I, -Qo 1IAAS��QLA_,� (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) I 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 /> EHO 29-0t 05,M12 WELL PERMIT APP <br />