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L V <br /> San Joaquin County Environmental Healtir Department <br /> WELL& BORINa PERMIT APPLICATION SUPPLEMENTAL. <br /> 1210 East Hammer Lane, Stockton <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter S (commencing with Section 7000) of <br /> Division 3 of the C+allfomia Business and Professions Code and my license is in full force and effect. <br /> License Exp Date: ,._..._ <br /> Date. —I 2 3 Contractor. -M Ski <br /> Signature: ���,, Title: ; Mzz�&—Cd <br /> Print Name: ,, <br /> .. � _�� ��115[JlL <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 /> compensatlon insurance carrier and policy numbers are: <br /> Carrier: st-w_ Twad Policy Number: )J '-1 1,7111 =L -- <br /> I certify that in the performance of the work for which this permit is issued, I shall riot employ any <br /> person in any manner so as to become subject to the wodters' compensation law of California, <br /> and agree that if t 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:, Slgr�hrre: � _-- <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNIAWRIL,AHD SHIALL BU&MCT AN EMPLOYER To <br /> CRnuAL PENALTIES AND CP41L FINES UP TO$169,A00, IN ADDmON T4 THE QOST OF COMPENSATION,MrERE.BT, <br /> ATTORNEY'$FEB,AND DAMAGES AS PROVIDED FOR IN SECTION 5706 OF UE LABOR CODE. <br /> AUTHORIZATI N R OTHER THAN <br /> igC�-5t77 SIGNING PERMIT APPLICATION <br /> i' ��DZ re A.t lice�ed author representative), <br /> hereby authorize(print narne)f I t)o l sign thin San oaquin Coun(t]I I S Boring Permit <br /> Application on my behalf. I understand this authorization Is vaad for one year and Is IlmttBd to the wont <br /> pian darted on the front paps of this application. <br /> EHo28-01 OWDW12 W&LPEAWAPP <br />