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�r <br /> V <br /> San Saaquin County <br /> Environmental Health Department <br /> W <br /> ELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> &A,�� PERMIT SR# <br /> 1,/,/o g7- {�^M r� <br /> JOB ADDRESS: <br /> LICENSED CONTRACTORS DECLARATION (.D) <br /> ion <br /> I hereby <br /> affirm that I am licensed under the provisions of Chapter Ig (commencing <br /> ri a Is. fulll force and#effec�00}. of <br /> Division 3 of the California Business and Professions Code an y <br /> Exp Date: <br /> License#: G� <br /> Date: <br /> Contractor: <br /> 1 _ <br /> signature: Title: <br /> Print Name: � <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 /> 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: o�� _ Policy Number: ®'/() /tea <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 tho4pr ' in . <br /> Exp. Date: : Signature <br /> Print Nam <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 /> U RIZ N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, (signature of C-57 licensed authorized representative), <br /> hereby a thorize(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 /> EHD 29-01 05/09112 <br /> WELL PERMIT APP <br />