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ti O.ct, 18. 2012 3:54PM No. 1456 P. 2 <br /> F <br /> 1 <br /> EFID2MI ID71MIC WELL PEl WAPP <br /> s <br /> San Jpagltin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL ; <br /> JOBADDREss: UJISPO kaW3_ SRMITSIS# <br /> LICENSED OONTRACTORS DECLARATION (LCD) <br /> I hereby affirm that I am licensed under the provisions of Chapter 8(commend ng with Section 7000)of ' <br /> Division 3 of the(~Business and Professions Code and my license Is In full orce and effect. <br /> t icense# e�i, L ,.�l' .r Exp Da#®: ' <br /> Date: Contractor; �-i, � <br /> Signatuie: Title: ,. <br /> Print Name: �i' Cf <br /> WORKERS'COMPENSATION DECLARATION <br /> F <br /> 1 hereby affirm under penalty Of perjury one of the following declarations:(check one) <br /> 1 have and will maintain a cefficate 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 111 <br /> f permit is issued. <br /> i1 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 thle,permit is issued. My workers' <br /> compensation insurance ca!Ver and pollcy numbers are: f c� <br /> Carrier: Policy Plumber, <br /> 1 certify that in the performance of the work for which this permit is issued,l shall not employ any <br /> person in any manner so as to become subject to the workers'compensation law of California,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Cod , I shall forthwith Comply with those provision <br /> Exp. 13ste: ! j Signature: <br /> Print'Name: C1/J <br /> WARNING:PAJIME To SECURE 1IVORKER6'COPAPEN8ATION COVERAGE IS UNLAWFUL,AND 814ALL,SUBJECT AN EXPLOYM TO <br /> cIt!>RMAL PENALTIES ACID CIVIL FINES UP TO$100,900,1N ADDITION TO THE COST OF COMPENSAMN,INTEREST. <br /> A11ORP EY S PEES,AND DAMAGES AS PROWDED FOR IN SEMION 3818 OF THE LABOR CODE. <br /> Tw IO OTHER T14AN C-57 SIGNING PERUT APPLICATION <br /> i, (signature of 0-87 licensad authorized representative), <br /> hereby authorize(pr(nt name) ,to <br /> sign this San Joaquin GOunty Wall&Boring Permit Application on my behalf. I understand this authorization <br /> Is valid for one year and is limited to Rhe work plan dated an the front page of this appilCatlon. <br /> PN029.01 0MWO MaPERMiTW <br />