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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: � l 1 (a La,5� iAfRer QA)'f SSD tPERMIT SR# <br /> c <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> 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#: -110 p] Q Exp Date: <br /> Date: Contractor: <br /> Signature: (\.a-),sr.n,t 1, Loan 11 Ldm Title: :3 A 4r% A,gt\}- <br /> Print Name: Q% 0(\c%tcN n F. t,�nn rk C <br /> J <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 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:nQI.)N jI& mt\ciRO a (;pR rgp Policy Number:QQp4oDDO()LAaE'% <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: Signature: Q &NN-z" � 1 '�o p["L r1 <br /> Print Name: (h nnc.Ult CF t)OC1 AA)Q.c- ,1 <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, S , m F (signature of C•57 licensed authorized representative), <br /> hereby authorize(print name) IA . ./F . 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 /> EHO2941 DsM12 WELL PERMa APP <br />