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San Joaquin County Environln antal Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ASO W_ 5� PERMIT SR# ^ <br /> I 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#: - - ''?- 0- Exp Date: `% <br /> Date: Contractor: i:1)t Itk,t tr ilFt 1�1t�,K'1 <br /> Signature: Title: <br /> Print Name: ') <br /> f <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 Section 3700 of the <br /> I Labor Code, for the performance of the work for which this permit compensation Insurance carrier and policy numbers are: p t i s Issued. My workers <br /> Carrier: STI-k C° � , r _ <br /> --, I <br /> f olicy Number: � �1 <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 tc the workers' compensation law of California, <br /> j and agree that if I should become subject to workE!rs' compensation provisions of Section 3700 of <br /> 1 the Labor Cade, I shall forthwith comply with those provisions. <br /> Exp. Date:! Signature: <br /> Print Name:'11- Ii; <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL.PENALTiEa .ApD CIVIL FINES UP TO $100,000, IN 4DDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,ANDOAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> R-OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby"authorize{print name} ppd1�,� )- To sign i:his 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 n dated on the front page of this application. <br /> SHO 29A1 uSJ09i;2 <br /> YJEI t PFRWYT A= <br />