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Sian Joaquin County Environmental Health Department <br /> MIELL&BORING PERVIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: `�^'�' i= , PERMIT SR# <br /> S �c c_/cT7t7 r _Q <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am lice sed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California B iness and Professions Code and my license is in full force and effect. <br /> License#: A ?D 6 0 E p Date: <br /> ra or: <br /> Date: M Con 4W 90I L <br /> Signature: Title: I Lq <br /> l <br /> Print Name. ` ) <br /> WORKERS'C PENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 /> compens on ins rance era policy numbers are: 1 ' <br /> Carrier: Policy Number: "1 oa�f��(✓-,/''1 �`lJ1 <br /> I certify that in the performance of the work for which this permit is issu , I sha of emplo n <br /> person in any manner so as to become subject to the workers' comp nsation la of Cal'omia <br /> and agree that if I should become subject to workers'compensation pro isions of Section 700 <br /> the Laboi Code, I ^hall forthwith comply with those pro ision <br /> Exp. Date: Signature: <br /> Print Name: I <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 18 UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES FINES UP TO$900,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> A;AU <br /> FORRATI <br /> ,AND AMAG S AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> F OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representativo), <br /> hereby authorize int name) "rJ jam, to sign this San Joaquin County Well & Boring Pormit <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 OSM12 WELL PERMIT APP <br />