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San Joaquin County Environmental Health Department <br /> WELL Er BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 50 7 CA 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 California Business and Professions Code and my license is in full force and effect. <br /> License* C,. 9G�`f`j9 Exp Date: 41 X70 1`4 <br /> Date: Contractor: �1�lecu're Dr-1O,tt <br /> Signal Title: CED <br /> Print Name:� � <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 /> 1 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: <br /> Carrier: %InkW UALiVIAOLQ, c )ca4!c� Policy Number: JvVY 1 ()q {0)-q <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 I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 24, 4 2 Signature: <br /> Print Name: -Ty � tJclJ.jZ,vt <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 /> A ORIZAT40N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I✓/ 4\w IJn we,*)IP,v� (signature of C•57 licensed authorized representative), <br /> herebyauthorize 4k�' <br /> (print name) Ix,�,�� I ��,.� �^ , to sign this San Joaquin County Well 8 Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 1901 0IM1 Z <br /> WELL PERMIT APP <br />