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1Ask Ak <br /> San J uin County Environmental Health Depart t <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL ll��Ky'6o <br /> JOB ADDRESS: ICO UCJYti Te Rt1t+IERMIT SR# DD(!021-5 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8 (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#: 703(a 3 g'7 Exp Date: 17311 7-01 ;t- <br /> Date: <br /> Date: 10 Contractor: Pf EGIS t Q4 SkM 0 W tJ fa, 11,)G. <br /> Signature U --- Title: DPE'P4N-n[705 V"A'6&1t. <br /> Print Name: ljf.er* blk U-1491)FOMt-Z <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 /> 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 /> compensation insurance carrier and policy numbers are: <br /> C MI <br /> Carrier:, s'+'b CA SoVA-L-fnl r y Policy Number: CPC-A- 091oly <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:_ I Sol 2,0 1 1 Signature: <br /> Print Name: 61-IJtDA C4-A-WFivi" <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 LASO'R CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> t, b£cEiJI A G Nf`0" nn (s�ignature of C-57 licensed authorized representative), <br /> hereby authorize(print nems) 1 Gli$5tL I�Uf i .to sign this Ban Joaquin County We11 $ 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 /> ems zso+ otrzWa <br /> iYELL Ptlwi ova <br /> a <br />