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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: B�� �lU —sYGr� lfle 2a1 PERMIT SR# <br /> -�raU� , <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licens d under the provisions of Chapter 9 (commencing With Section 7000) of <br /> Division 3 of the California <br /> �Busin ss and Professions Code and my license ik in full Pree and effect. <br /> License#: C v Exp Date: Q I �00 U <br /> Date: Contr tor. <br /> 1 <br /> Signature: itle: <br /> LIT <br /> Print Name: � <br /> WORKERS' COMPEN ATI N 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 /> 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 /> compensat' i sura ce�jr and pot' y numbers are: l /n '� <br /> Carrier: I Policy Number: , �J�( i <br /> 1 certify that in the performance of the work for which this permit is iss d, I s it not employ any <br /> person in any manner so as to become subject to the workers' co pensation aw of California <br /> and agree that if I should become subject to workers' compensation p visions o Section 370 of <br /> the La]b�or'Cod , I(shh 11 forthwith comply with those provis' ns. <br /> Exp. Date: V I Signature: � <br /> Print Name: <br /> ►/ l� /� <br /> WARNING:FAILIL <br /> RE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTS,AND DAMA�+E PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> TION FOR HER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby author a(pri t name} �V it to sign this San Joaquin County Well & Boring Permit <br /> Application on half. 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 /> END 2901 05/09112 WELL PERMIT APP <br />