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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: /'357 Sar, IAJ. Qr.�yy L,� t-� PERMIT SR# <br /> 'TY-c,/j Cr" 175 3o y <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-57 953646 Exp Date: 10-31-2014 <br /> Date: 4-29-2014 Contractor: NATIONAL EWP, INC. <br /> Signature:/ T1t1e: PROJECT SUPERVISOR <br /> Print Name: CHRIS TATUM <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 workers' compensation, as <br /> provided for by Sectlon 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> 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: ZURICH AMERICAN INS CO. Pollcy.Number: WC931933202 <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 /> 2-].1-2°14 <br /> Exp.Date: Signature: � --- <br /> 6 <br /> Print Name: CHRIS TATUM <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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, <br /> CHRIS TATUM (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 'i} i RA TECH , to sign this San Joaquin 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/OW12 WELL PERMIT APP <br />