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San Joaquin County Environmental Health Department <br /> j WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 32 SD W_ o-,,,,,, A PERMIT SR# <br /> LICENSED CONTRACTOR`, DECLARATION (LCD) <br /> 1 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 /> ;- <br /> License#: c Exp Date: ' U } <br /> Date: Contractor: <br /> ` <br /> Signature ...- Title,- _ k (:j <br /> Print Name: V 6 "" <br /> r <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> 1 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 thisermi <br /> compensation Insurance carrier and policy numbers are: p t i s Issued. My workers <br /> Carrier: r Policy Number: <br /> I .,-ertify 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 t:) the workers` compensation law of California, <br /> j and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> I the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Dater`~_ _. g <br /> Si nature;� <br /> Print Name: <br /> 1 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 /> _AT70RNEY'S FEES,.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATI - -OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 9-ze/k ,A J. o 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 /> 1 plan dated on the front page of this application. <br /> EHD 29 0t 0."9/12 <br /> WELL PER+BT APP <br />