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v <br /> San Joaquin County Environmental HeaM Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL. <br /> 1210 East Hammer Lane, Stockton <br /> JOB ADDRESS: PERAIIIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that 1 am licensed under the provisions of Chapter 8 (commencing with Section 7000) of <br /> Division 3 of the <br /> C�alifbmla Business and Professions Code and my license is in full force and effect. <br /> License Exp Date. -UD __ <br /> Date. (� -t(�—� a l Contractor: Jkl Well .Y1r 11 <br /> Signature: Title:2ULX&cr4 <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 /> I have and will maintain workers' compensation insurance, as required by Sectlon 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. 1'! `� <br /> I certify that in the performance of the work for which this permit: is issued, I small not employ any <br /> person in any manner so as to become subject to the workers' Compensation low aF 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 provlslons. <br /> Exp,Date: Signature: — <br /> Print Name: <br /> WARNING:FAIWRE TO SECURE WORKERS'comPENSATION COVERAGE IS UHI.AWFUL,AND SHALT.SUBJECT AN EWLOYER TO <br /> MURAL PENALTIES AND CIVIL FINES UP TO $16A,A06, IN AMMON To 711E COST OF COAII'ENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN BEC 10H 8786 OF THE LABOR CODE. <br /> AUTHORIZATI N R OTHER THAN C-E7 SIGNING PERMIT APPLICATION <br /> l� s "°�f icenaed a <br /> representative), <br /> rc �ts� +�t.l>JC <br /> hereby authorize(print name) LI , to n n quin County I Boring Permit <br /> Application on my behalf. I understand this authortwdon Is valid for one year and lel limped to the work <br /> pian dated on the front page of this application. <br /> EKO Y8-o1 abioewi2 WELL PURMfr APP <br />