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San J in County Environmental Health Departt <br /> WELL & BORING PERMIT /APPLICATION SUPPLEMENTAL <br /> 0 l��Ky'so <br /> , �,�,,'' tt// C <br /> JOB ADDRESS: KO (y-&l `J tmr\ To-1Z rK I ERMIT SR it 0 /J <br /> 0060 9 <br /> LICENSED CONTRACTORS DECLARATION (!,CQ) <br /> I hereby affirm that 1 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 #: (03 fp Exp Date: 1 / 2,11 2-01 a- <br /> Date: Contractor: Pfec4sfQ4 SAH0L- iU;&, tiJG. <br /> Signature: _�-'^_J Title: I�PEf #1 i IytJS {AA fi1.h{ lt <br /> Print Name: P�R FN DR <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 /> 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 /> COMfANtOn1 Ptet? e'aaTl UC-A- IDq(�,(d <br /> Carrier. "b VAI--T'y Policy Number: <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: �' 30 2 t7I i Signature: L <br /> Print Name: 60--K)DA C#-.�F=z'i" <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100.000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> �#J p}4 }2�1tA16 ti4 (signature of C-57 licensed authorized representative), <br /> njilUL <br /> hereby authorize (print name) {11L1i5$LL (I �to 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 /> W Fi.t FQ4i'APa <br />