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San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> p ) `�`! C <br /> Jab ADDRESS: an� Q,,t jvy-4 4 15`Lf51 F JK PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that l 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 F7te <br /> and effect, <br /> License#: 4t C�. Exp Date: i t 3 C <br /> Oate: to t f Contractor; <br /> Signature: 'title; CZ_-4 <br /> Print Name: <br /> WORKERS,COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check ane) <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 /> 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 an d policy numbers are: <br /> Carrier' �� �� } s t policy Number: O <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 1 should become subject to workers'compensation provisions of Section 3700 of <br /> the LaborC ds, I hall forthwith com ply with those provisions. <br /> Exp. Date• �'j , r t ( Signature: <br /> Print Name:__' (—cam ✓ Gi�w, e.,•�— <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 /> ATTORNE'Y'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTH Z,ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby a orae(print name))Q-F/j`� 7—.!=.-I 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 /> pian dated on the front page of this application. <br /> EHazao, m.ar,u <br /> WELL PERMIT APP <br /> TI/£0 39tld 1­10310KAN3 X3dd LLTOTS89T6 L£:£Z OTOZ/0Z/TT <br />