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i <br /> 1 <br /> 44 <br /> 1 <br /> EHD 29-01 07/20/10 - WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> I WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS: 5S0,3 I\��y���s;y(? S>tz,c�c �I 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. . : I <br /> / l <br /> License#: CS�7 `fg.�/�� Exp Date: <br /> Date:�/ 3 Contractor: <br /> Signature: Title: <br /> I Print Name: - <br /> I <br /> WORKERS' COMPENSATION DECLARATION I <br /> fI 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 1 <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this I I <br /> permit is issued. i { <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: Q <br /> Carrier/ `p/''G� Policy Number/T�L /� <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 Dater <br /> �f Signature: s °I <br /> Print Name: i^� <br /> I's <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, ! iyt.�., (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 j. <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 07!20/10 i1. <br /> WELL PERMIT APP I;:i <br /> 1' <br />