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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 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 <br /> lifornia Business and Professions Code and my license is in full force and effect. <br /> `7 <br /> License#:C 57 '�'��_��� -2 Exp Date: V.:36—I& <br /> Date: /�iQ2Z— Contractor: d) <br /> Signature: 4 Title: <br /> Print Name: <br /> Name: OGNN 1 S <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 /> _L 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: JC <br /> Policy Number: �U 6'�-7C-- r>/ 3 <br /> 1 certify that in the performance of the work for which this permit is iss ed, I shall not employ any <br /> person in any manner so as to become subject to the worked'co r Pensation law of California, <br /> and agree that if I should become subject to workers' com t5�atlo- rov s of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provi 'o % <br /> Ex Date:_ �� -/—/ <br /> Exp. � Signature: / <br /> Print Name: <br /> WARNIN : FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CWMINAL,PENALTIES�AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> A RN �PJXWGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATIO /FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) Lesb�t ,S , I,ol , to sign this San Joaquin County Well & Boring Permit <br /> Lt,rf <br /> Application on my behalf. I unders an this au horization 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 05/09/12 <br /> WELL PERMIT APP <br />