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� l <br /> f <br /> San Joaquin County Environmental Health Department <br /> WELL &BORING:PERM'T APPLICATION SUPPLEMENTAL j <br /> I. <br /> li ! 401 East Fiero. Camp Roach,, French h Carne <br /> JOB ADDRESS. _ PERMI.TSRf I <br /> LICENSED CONTRACTORS DECLARATIONLCD <br /> I, <br /> �-3 <br /> heresy affirm. that 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 fuii force and effect: <br /> License=. ',43?50 Exp Date,. 2�':31/30 <br /> --— <br /> 9 107 J10 ERRG Inc. <br /> Date: Cwntractor: <br /> Signature: ,r ,. Title .__ <br /> Print Name;- ;I. �� ,fid j <br /> i <br /> WORKERS'COMPENSA`f#O1V dECLAP.AT#ON k <br /> ! hereby affirm under penalty of periuty one of the following declarations: (chec#c one} <br /> I <br /> j I have and will maintain a ceftificate of consent to self Insure for workers' compensation:. as <br /> provided for by Section 3700 of.the 'Labor Code. for the perforrrianoe of the work for which this <br /> permit is issued- } <br /> j X ! have and will maintain workers' compensation insurance, as required by Section 3700 of the C <br /> Labor Code.. for. +he performance of the work for which this permit is issued. My workers' <br /> compensation insurance carrier and oolicy numbers are: <br /> Carrier: Zurich Fiin.ericar Insurance WC9I389403'. <br /> Policy Number: <br /> 1.cert!4-,that in thP.performance of the work foe which"this permit is issued. I shall not employ any i I <br /> person in any manner so as to become subject to the workers' compensation law of California, : <br /> and agree that if,should become subiect to I workers`compensation provisions of.Section 370I?of I <br /> the Labor ode..f shall forthwith comply with those provisions--A <br /> Exp. Date: `� 0 f20i1 Signature:.. <br /> Print Name: �� c <br /> WARNING.FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF GOr$PeN$ATIOW,.}NTERESr, <br /> ATTORNEY'S FEES.AND DAMAGES AS PROVIDED FOR IN.5ECTIOIJ 370&OF THE LABOR CODE. <br /> : I <br /> AUTHOR ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLIQATION <br /> (signature ef-� licen4rd authorized representative), ' <br /> herebyauthorize.(Print name)Anna.. Radonichto slan this San Joaquin County <br /> Well & Boring Permit <br /> i Application on my behalf. 1 understand this authorization is. valid for one year and is limited to the wort: <br /> I pian dated on the front page of this application.. � <br /> I <br /> l <br /> I <br />