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_............+_._......-...._ <br /> San Joaquin County Environmental Health CIopar:ment <br /> WELL & BORING PERMIT APPLICATION &.IPPLEMENTAL <br /> 230 N Church St,Lodi.CA 95240 <br /> JOB ADDRESS: F UAIIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 c}rrmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my lic,�rse; is in full force and effect, <br /> License#: � 1 I =xp Date: <br /> Date: Contractor: <br /> Signature: �- Title: <br /> Print Name: l�f AA' <br /> WORKERS' COMPENSATION DECLA:,ATIJN <br /> I hereby affirm under penalty of perjury one of the following declaraticl,ls: (,;heck one) <br /> I have and will maintain a certificate of consent to self-ir:u-e for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the pc`c-n-ance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, a� r,-quired by Section 3700 of the <br /> Labor Code, for the performance of the work for which phis Kermit is issued- My workers' <br /> compensation insurance carrier and policy numbe-s are: -7 <br /> Carrier: Policy Nur-ber � <br /> I certify that in the performance of the work for which this PE-Mit :s issued, 1 shall not employ any <br /> person in any manner so as to become subject to the wor,.yrs' compensation law of California, <br /> and agree that if I should become subject to workers' compE s 3t :)n provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provision: <br /> Exp. Date: _ , Signature: <br /> Print Name:--- I-'�'i.,��:t✓ � <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLA%A U;.,:`,ND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION T: THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 CI-THIE LABOR CODE. <br /> AUTHORaAT I:HER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-5' licensed authorized representative), <br /> hereby orize(pri / name) to sign this San ,lallquin County Well & Boring Permit <br /> Application on my behalf. 1 understand this authorization is valid fc;- une year and is limited to the work <br /> plan dated on the front page of this application. <br /> EH029-01 M09112 WELL PERMIT APP <br />