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Jul. 31. 2012 11 :48AM No. 1037 P. 14/16 <br /> 2HD 29-01 0112a1 i0 WELL PERMrrAPP <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOR A+DD1115SS: _','�.=::tr i 1 t�ii t i� ..� . L- ,�':'1���J ,,ti'4 PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD_) <br /> I hereby affirm that l am licensed under the provislons of Chapter 9(commencing with Section 7000)of <br /> Division 3 of the Business and cProfessions Code and my license is in full force and effect. <br /> License#: Date: I h�4 <br /> Date. -Contractor: <br /> Sfgnature: Title:—��l—•��j9/ '�" ,r Ara,,g ' , <br /> r <br /> Print(Name: 1 <br /> I <br /> WORKERS' COMPENSATION brCLARATION ! <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> 1 t 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 I <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: / 6 <br /> Carrier: i/ Policy Number: . <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 1 should become subject to workers'compensation provisions of Section 3700 of the <br /> labor Codel I shall forthwith comply with those provisi <br /> Exp.[date: Signature: <br /> Print Plaine:O/ -Cf` <br /> WARNING,FAfLURE TO SECURE WORiMRS'COMPENSATION COVR-RAGE 4 UNLAWFUL,AND SHALL SUBJECT AN FWLOYER To <br /> CRIMINAL PENALTIES AND CIVIL FINE$UP TO$100,000,IN ADDITION TO THE COST OP COMPENSATION,INTEREST, <br /> ATTIORNEWA FEC9,AND CANIAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> U ! FOR OT14ER THAN C-67 SIGNING PERMIT APPLICATION <br /> i, (sigrt auto of"7 licensed authorized representative}, <br /> hefeby au iorizo(print name) ,to, <br /> sign thio San J+oaquln County Well#,Boring Permit Apprication on my behalf. i understand this aufhorrizatlon <br /> is valid for one year and is limited to the work plan dated on the front-page of this application. <br /> DO 2M1 07AM0 VVELL PEROTpPP <br />