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Oct, 18. 2012 3:54PM No. 1456 P. 4 <br /> . I <br /> i E11020-01 07tzW10 WELL PERMIT APP <br /> a <br /> San Joac{uin County Environmental M®alth b®partment <br /> WELL&BORING PERMIT APPU cA7lON SUPPLEMENTAL <br /> r <br /> JOS AOOrSS: w�. Sit# <br /> LICENSED CONTRACTORS DECLARAi°IONLam} <br /> I hereby affirm that l am licensed underthe provisions of Chapter 9(commencing with Seotlon 7000)of <br /> Division 3 of the Business and Professions Code and my ilcense Is In full orce and effect. ' <br /> License#: ' C12 �—r'46 1— ncp Dake: <br /> Date: b Contractor. '�.1•p.Ggi+l <br /> Signature: Title: �' ;� C•' G{ <br /> F 1 <br /> Print Name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of peiJury one of the following declarations:(check one) <br /> I nave and will maintain a certificate of consent to self-Insure for workers'compensation,as <br /> provided for by Sectlon 3700 of the Labor Code,for the performance of the work far which this <br /> pen,nit is Issued. _ <br /> I have and will maintain werl<ars'compensation insurance,as required by Section 37.00 of the <br /> l Labor Code,for the performance of the work for which this permit Is li sued, My workers' <br /> compensation insurance ca, Jer and policy numbers are: <br /> Colder: PailCyr Piumloer: <br /> 191rCw 040/MO <br /> 1 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 Calffornia,and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, ishall f rthwlth comply with ihose provision <br /> EAP. Date: +� Signature- <br /> PrinE Mama• r !' � <br /> WARFANG:FAILURE TO SECURE W0RKr%R&C0MF5WATION COVERAGE IS UAfLAWFUL,AND SMALLSUBJECTAN IaMPLOY1=RTO <br /> CRIMINAL PENALTIES AND CML FINEST UP TO$700,000,IN ADDITION 70 THE COST OR OOUPeNBAT10N,INTEREST, <br /> ATTORNEY$FEE$,AND 13AMAGM AS PROVFDED FOCI IN SECTION 3708 OF TNM LABOR COOS. <br /> THrO OTHER THAN O-67 SIGNING ioERVIT APPLICATION <br /> I, (signaftIre of C-57 IIcansed authorized mpresantative), <br /> hereby aut7o�ze(print name) ,to <br /> sign this San Joaquin County Won&Boring Permit Application on my behalf. I understand this authorization <br /> is valid for cone year and Is Ilmlted to the work plan elated an the front page of this appilcation. <br /> EN02PV 07MIO 1AELLPIAWYAPP <br />