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Ct 1 <br /> F <br /> C <br /> FHD 29-01 07/20/10 WELL PERMIT APP <br /> I San Joaquin County Environmental Health Department <br /> I WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> 7 T ( I <br /> JOB ADDRESS: __!305 ��ry�/ lJy�y(? i S�zc�ia� PERMIT SR# <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 Business and Professions Code and my license is in full force and effect. ! <br /> License#: -CS �g-�� Exp Date: <br /> f t <br /> I <br /> Date: 9 / 3 Contractor. <br /> 1 I l i <br /> Signature: iy.yr— Title: e25za, 5;p j <br /> Print Name: <br /> I ' <br /> WORKERS'COMPENSATION DECLARATION i <br /> I <br /> I <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> i <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 j <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, as required by Section 3700 of the 1. <br /> Labor Code,for the performance of the work for which this permit is issued. My workers' j <br /> compensation insurance carrier and policy numbers are: Q <br /> Carrier�rol-,6 Policy Number&CWO�0 t//U'/ <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, and <br /> - agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:.S/alZZ Signature: <br /> Print Name: �^,v <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 /> THO ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, �' - (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) to <br /> sign this San Joaquin County Well &Boring Permit Application on my behalf. I understand this authorization �. <br /> is valid for one year and is limited to the work plan dated on the front pago of this application. ...s <br /> EHD 20-o1 07120/10 YIEI <br /> mu. li:? <br /> Irh,. <br /> U I <br /> i" <br />