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41 <br /> i <br /> EHD 29-01 07/2D110 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> ° FADDRESS: <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> F <br /> �. <br /> dT 1*84, <br /> I l74,R4, 7 C/IPERMIT SR# _ Y <br /> s <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> f <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full force and effect. <br /> License #: CSS ��1^/� ExpDate <br /> Date: Contractor: <br /> Signature: / Title: 40?�/ <br /> Print Name:_ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> — <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 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 /> I <br /> Carrier: SCcy�// j�f Policy Number: W qO 26Z <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, and <br /> agree that if I should become subject to workers'compensation r isions of Section 3700 of the <br /> Labor Coddee, I shall forthwith comply with those provisio <br /> Exp. Date: O �3 l(C� Signature: 1 <br /> Print Name: 6 l-C///f,��q//Lo/ <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 /> O ►TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> pp (signature of C-57 licensed authorized representative), <br /> hereby a thorize(print name) _ "PT- f1&5kIE{7 <br /> to <br /> sign this San Joaquin County Well & Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHD 29.01 07/201ID <br /> WELLPERMITAPP <br />