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Ah Ak <br /> San JM&uin County Environmental Health Departs, t <br /> WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOS ADDRESS. K041 Te_Q OX rr�PERMIT SR# O l 37i <br /> 25 WI <br /> LICENSED CONTRACTORS DECLARATION CLCD) <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#: &3 i�P 3 8'7 Exp Date: it 3 t 1 2-012- <br /> Date: <br /> -y11- <br /> Date: _ d D Contractor: NkEG5I04 5A4-10W,U67, I1JC. <br /> Signature: _,..,..- Title: 099 R-A-n0t S M"A1G6FK <br /> Print Name: CAA•WF'OIL-0 <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 worts for which this <br /> permit is issued. <br /> I 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 /> compensation insurance carrier and policy numbers are: <br /> CDM WrIj10 P90PeaLty GPGA ID <br /> Carrier: "b CA-5VAvrt.� Policy Number: 1940&&7 <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 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 Code, I shall forthwith comply with those pr visions. <br /> Exp. Date: to Signature: L==::�= <br /> Print Name: 60,r- DA C.1ILAW F=iV" <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUaJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES.AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LA80R CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I bizela-0 t C"Wf^DA• D �(signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) R 61654- 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 /> plan dated on the front page of this application. <br /> ErA729m' 6ltV,J /see:.R�>.ulT ao> <br /> 4 <br />