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— -- San Joaquin County Environmental Health.V'Department <br /> WELL & BORING PERMIT APPLICATION !6UPPLEMENTAL <br /> JOB ADDRESS: 37S W • 1AAZel�rt ,A re. PERMIT SR# <br /> s TOCK row C-P} <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter I Iccmmencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my llufnse is in full force and effect. <br /> License#: C7 F C) 3eJ� Exp Date: p` 'A 301 2DE()_i <br /> ��e'� 1, Contractor. { I` <br /> Date: � AW <br /> Signature: Title: « � <br /> Print Name: <br /> WORKERS' COMPENSATION DECL IRA11ON <br /> I hereby affirm under penalty of perjury one of the following declara:ions (check one) <br /> 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 Iser"o mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insuranci:: 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: i <br /> Carrier:10 �1 . Policy N:Imbi;r: <br /> I certify that in the performance of the work for which this I:ermit is issued, I shall not employ any <br /> person in any manner so as to become subject to the weaker:" compensation law of California, <br /> and agree that if I should become subject to workers' compersa:tion provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: QC`�'IYl S� 1I � '�,�-� <br /> gn:�a <br /> ure• �--� <br /> Print me: ;QC ; � <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLA:i1FUL. AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TC THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 37011 OF THE LABOR CODE. <br /> AUTHOR OTHER THAN 0-57 SIGNI?113 PERMIT APPLICATION <br /> I, .�' ' (signature of C-,7 lkensed authorized representative), <br /> . <br /> ereby vthoriz pant name} /ren C-JOAof , to sign this Saii Joaquin County Well & Boring Permit <br /> Application on my behalf. i understand this authorization is valid for une year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 07RWIO WELL PERMIT APP <br />