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� � t4� t •� ! r� r`� <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 2402 south California Street,Stockton,CA 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#: �( � U Exp Date.- <br /> Date: <br /> ate:Date: / ( �I (_ y- Contractor: EPI V , A-;,pC r <br /> Signature: "'7 ZL Title: IF /-I- <br /> Print <br /> Print Name: <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 wgrkers' 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: <br /> re:Carrier: Policy Number: <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 s Signature: <br /> Print Name: <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 irODE. <br /> -A )THORIZATfON POR OTHER THAN C-57 SIGNING PERMIT i PPLICATION <br /> I, 1 y (�� / (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)­'416 l�/�lcti/oto sign this San Joaquinn 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 /> EHD 29-01 05/09/12 <br /> WELL PERMIT APP <br />