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Jul, 31, 2012 11 :47AM No. 1037 P. 10/16 <br /> % , <br /> ER04 -01 071*10 WELL PERMIT AP# <br /> San Joaquin County Environmental Health Department <br /> WILL&BORING PERMIT APPLICA-nom SUPPLEWNTAL <br /> J 0 H ADDRK88; A P>=RNf11T SRS <br /> LICENSED CONTRACTORS DECLARATION (LCq) <br /> ,S <br /> I hereby affirm that I am licensed under the provisions of Chapter Ig(commencing with Section 7000)of <br /> Division 3 of the Business and Professions Code and my license is in full fa ce and effect, <br /> License A C.'s-? <br /> Exp Date, ` <br /> Date: Contractor_ it-�'� { <br /> I i <br /> Signature: Tide: r'`l//O' 1 <br /> Print Nalne: �Crr l/ <br /> WORKERS'COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declaratlons: (check one) € <br /> 1 have and will maintain a certi icate 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 /> E <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: ,.�7 <br /> CQrrlor: &�d- Policy Number: _15YCW190"rJ <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,and <br /> agree that if 1 should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply with those provisions. <br /> Exp.Da4e: �I? -- Signature: <br /> Prlrft Name: -✓ C/' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAC+E IS UNI AWVUL,AND SHALL S013JECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINS3 UP 10$100,400,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S 1`91115,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THIii LABOR CODk. <br /> TI-I OR OTHER''li HAN C'S7 SIGNING PERMIT APPLICATION <br /> r, (signature of•C-57 Nonsed authorized representative), <br /> hereby authoriz®(print name) ,to <br /> sign this$an Joaquin County Well&Boring Permit Application on my behalf. I undorgtend this authorization <br /> Is valid for ono year and Is limited to the work plan[sated on the front page of this application. <br /> a+Dza-M MOO 'AMLMMITAPP <br />