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or <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: C �r'�+�� L- L� �f�c� CC� 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 Business and Professions Code and my license is in full force and effect. <br /> License#: C .7 17o .<M Exp Date: <br /> Date: Contractor: Pet'1P11, 11t. <br /> f' <br /> J <br /> Signat Title: CEO <br /> Print Name: wnN) <br /> WORKERS' COMPENS ATION DECL ARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 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: 1tJ�(,o , A)rnZc,,n\ Policy Number:,\r., 1+n1 ;I)qq 0)J <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:6_� ZU\�� Signature: <br /> Print Name:_ --rVkrJ iicoun <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 /> A ORI ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> of C-57 licensed authorized(signature h d representative), <br /> herebyauthorize '�� <br /> (print name) � `{ , to sign this San Joaquin County Well 8 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. L <br /> EHD 29.01 05.'09!12 WELL PERN,iT APP <br />