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EHD 29-01 0720/10 WELL PERMIT APP <br /> _ I <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 201Aa I C1 \ PERMIT SR# <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 <br /> Business and Professions Code and my license is in full f rccee la d e ect. <br /> License.#:. I Ex Date: <br /> Date: ( ontractor: �V n t l V1I w4w I -J <br /> Signature: ►'`l.� �� Title: <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 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 /> compensatio / <br /> insurancFul <br /> ecarrier an policy numbers are: <br /> Carrier: (/ Policy Number:, <br /> 1 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' compensatio w of Califo ia, and <br /> agree that if 1 should become subject to workers' compensation provisions f S coon 3700 f the <br /> Labor C de, I [hall forthwith comply with those provisio s. <br /> Exp. Date: Signature: 1. iq ' <br /> Print Name: Y I <br /> WARNING:FAILURJ,,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 /> AU O ATION FO4THER THAN C-57 SIGNING PERMIT APPLICATION <br /> signature -57 li ensed authorized representative), <br /> ( <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin County Well & Boring Permit Application SdI my belialf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 29-01 0720/10 WELL PERMIT APP <br />