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21, �► <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTALL <br /> JOB ADDRESS: 5,42, C• 6� ` Tia y PERMIT SR# V & <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#: CS 7 YA!:(1K Exp Date: <br /> Date: Contractor: <br /> L[ a <br /> Signature: Title:92fLe 7//wr <br /> Print Name: (Shn;r-6 (o/ phn,4,7p1— <br /> 1 <br /> WORKERS' COMPENSATION DECLARATION 3i <br /> I 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 I <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which this ! <br /> permit is issued. <br /> _I have and will maintain workers' compensation insurance, as required by Section 3700 of the i. <br /> Labor Code, for the performance of the work for which this permit is issued. My workers' j <br /> compensation insurance carrier and policy numbers are: <br /> Carrier: S {77 �� Policy Number: ts(�✓������ <br /> 1 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 provisl <br /> Exp. Date: R/�f�// Signature <br /> ( + <br /> Print Namei_./"I/�/,l"7C�0 <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 /> AUT ORI7QT[ON FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, 7,f�C w'f"//G•2� - y (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) N% , 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 /> EHD 29D1 071$880 WELL PERMIT APP <br />