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I l <br /> j San Joaquin County Environmental Health Depaltmen <br /> j WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS <.:? ( :��r:� �.,;r� � (�. —��t�c � <. ��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 /> fLicense#: I ; L. : Exp Date: _ I 1 (L I <br /> P <br /> Signature I L — s �_-- Title: <br /> Date Contractor <br /> 1 . - <br /> 9 — <br /> Print Name:Jf/-k- <br /> i <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <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 <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: J la j��r Policy Number: &/ 7r) _ <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: � ��/� Signature: <br /> �1� <br /> Print Name:C�/%I/ P1-0"1lC?/ <br /> '., WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENAI-TIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATT'ORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> UT RIZAA ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-67 licensed authorized representative), <br /> hereby au prize (print name to sign this San Joaquin County Well & 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 /> 'zHD2 01 07/28110 NF PERf.9TAPP <br />