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San Joaquin County Environmental Kealth Department <br /> WELL&SORUNG FERMET APPLICA.TEOM SUPPLEM� Eit T AL <br /> JOB ADDRESS: PERMIT SCS <br /> LICENSED CONTRACTORS DECLARATi N (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 8 siness and Professions Code and my license is in full force and effect. <br /> License#: Exp Date: <br /> Date: Contra or: <br /> �� <br /> Signature: <br /> Title: <br /> Print Name: tier ! I <br /> WORKERS' C J WPE€SA-Tli0W DECLA,R h X0,14 <br /> hereby affirm under penalty of perjuny one of the following declarations: (check ane) <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 /> con.pens on insurance r.2mer a d policy number are: <br /> PONCY Nun or: <br /> I certify that in the performance of the work for which this permit is issue , I shad dot emplo ' un' <br /> person in any manner so as to become subject to the workers' compnsation law of California, <br /> and agree that if I should become subject to workers' compensation pro isions of Section 13700 <br /> the Labbo Code, i hall forthwith comply vvith those pro ision�� <br /> Exp,. Date: ! Signature: iR �,,` ' <br /> Palm Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL_AMO SHALL SUBJECT AN EMPLOYER TO <br /> CM11AINAL PENALTIES AP! FINES UP TO 5100,000, !N ADDITION! TO THE COST OF COMPENSATION, WNTEREST, <br /> ATTORN SEES,AND AI�iAG S AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU11 0RI➢ TZ44 AFI ' OTHER THAN C-57 VOKHRIG PERfO T APPLVCAMOHO <br /> (signature of C-57 licensed authorized represontative?, <br /> l <br /> hereby authorize( }�nt narne)\-� to sign this Sart Joacuin. County Well & Boring Permit <br /> Application on my behalf. B understand this authorization is valid Gcr one year end is limited to ';he wark <br /> plan datied on the front page o:'•this application- <br /> EHD 29-01 05/09/'12 WELL PERMIT APP <br />