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San Joaquin County Emrirornrrental Health Department <br /> /fW/E/LL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ?t <br /> JOB ADDRESS: 1 ak Ot-Co' ZA&L 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 /> License ` . 7 Exp Date: `2 r' ' <br /> Date: y,I d _ Contractor: <br /> Signature: r �ti TMe: �fii_ CP HQt1 <br /> Print Name: La"}t5 <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 Cade, 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 /> Carrier: Policy Number: <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 /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3705 OF THE LABOR CODE, <br /> =,THTIONI�FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> -' C. (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> em zeal aemnz wF11 PHaI$T Ai4 <br />