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EHD29-01 07/20/10 WELLPERN,I T APP <br /> San Joaquin County Environmental Health Department <br /> i WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: _ 5.S05 �I�y•i�v;v(?� S�r,c +a�. 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 Cade and my license is in full force and effect. :A s <br /> C.s? VSS/�` / <br /> ` License#: Exp Date: <br /> I. <br /> Date: 9 / 3 Contractor: <br /> ' I <br /> Signature: ''�''�—r— Title: <br /> Print Name: <br /> WORKERS'COMPENSATION DECLARATION ! f <br /> I <br /> f I hereby affirm under penalty of perjury one of the following declarations: (check one) � I <br /> I f <br /> i <br /> E 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. { 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 insuraante carrier and policy numbers are- <br /> Carrier <br /> re: Q <br /> Carrier/9(p/'a Policy Number&a4/0/0 1 //0/ <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 /> _ r , <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date:.,3L�L,,,• i•:.. <br /> /Z�f Signature: <br /> Print Name:- <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. l <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 page of this application. <br /> r <br /> EHD29-01 07120/10 <br /> I <br /> WELL PERMIT APP <br /> Ps ' <br /> j; <br /> Y. <br />