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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: LM I PpctF i Aue. !SDL.PNrJGay PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the Califomia Business and Professions Code and my license is in full force and effect. <br /> License#: q,� p q Lo Exp Date: 117,-,,!62 <br /> Date: tZIt5-1z p1 Contractor: Ala�(OrtctI 6JPJ /Ac - <br /> Signature: Title: (p') M,a kJ Ol_ <br /> Print Name: TIATU Y`-\ <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 /> i have and will maintain workers' compensation Insurance, as required by Section 3700 of Line <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: t I <br /> Carrier: �V (lGl l �-eV\C ctv-) Policy Number: W c cub �7 20q <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: C Signature: <br /> Print Name: l j 71 TU N� <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$700,000,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 /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, l J�f l A-I 1J 11V/ — (Signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 5ZQp,A�i'l=r_ , 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 /> E Dx l m 12 WELL PERMIT MP <br />