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swo ' <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: iV If- W�Ti AIM 69 I-A1S E PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (CD) <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 Cotte and my license is in full force and effect. <br /> License#: '13 4 Exp Date: �l <br /> Date: Contractor-_raSrAe- `yn f lt?, <br /> Signature: Tale: <br /> Print Name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> 1 have and vAll 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 /> x 1 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 /> compensate n insurance carrier and policy numbers are: 5���' <br /> opw <br /> Carrier. Ci'vE4+ \ I 11A <br /> t ,' _ Policy Nurttber J <br /> f0 <br /> 1 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 Cade, I shall forthwith comply with those provisions. <br /> Exp. Date: 10 Signature T�....- <br /> Print Name:PC tt t �1 tlt <br /> WARNING.,FAILURE Tia SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP To $100,000, 1" ADDITION TO THE COST OF COMPENSATION,IXTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED,FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A=namel, <br /> R THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby aut , to sign this San .loaquin County Well 8 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 /> FJii7 29-01 Q7 MIG WELLPERyIfT APP <br />