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Ju 1. 31. 2012 11 :46AM No, 1037 P. 2/16 <br /> �r <br /> E41)29-01 0712eHo Wat PPRMrr APP; <br /> San Joaquin County Environmental Health D9partmorpt ' <br /> WELL&BORING PgRw AppucATI N UPPLEINi1=td` AL <br /> 3 4 <br /> JOR ADDRESa: r:;.,:.; °;., 1. ,} <br /> LICENSED CONTRACTORS DECLARATION (LC) <br /> hereby affirm that I am licensed under the provisrons of Chapter 9(commencing with Section 7000)of i <br /> 0ivislon 3 of the Business and Professions Code and my license is in futf�rce and effect. <br /> License 47G 2 �, 1� Exp Date: <br /> Date: l Contractor.' ' <br /> Signature: Title: <br /> Print Name: r U <br /> WORKERS'COMPENSAMON TCI ARATION <br /> I hereby affirm under penalty of perjury one of the following declarations:(check one) <br /> I have and will maintain a celtiflcate 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 <br /> Labor Code,for the performance of Iie work for which this permit is issued. My Workers' <br /> compensation insurance c§rner and policy numbers are: <br /> Carrier: Policy Number: +� �v('"Y lr <br /> I certify that In the performance of the wor(c for whioh#his permit is issued,1,31911 not employ any <br /> person in any manner so as to become subject to the wori<ers'compensation law of California,and <br /> agree that if l should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code, I shall forthwith comply With those provis" <br /> t <br /> I <br /> Exp.Date: _ Signature: <br /> Mint Name:-/ <br /> I <br /> I WARM11G:FAILURI:To SECURE wORKE-119'OOMPENBATICN COVERAGE IS UNLAWFUL,AND SMALL BUEJECT AN EMPLOYER TO <br /> I CRIMINAL PENALTMS AND CMI.FW B UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROM090 POR IN SECTION 3706 OF THE LABOR CODE, <br /> �11ZeTIOR OTHER THAWC-57 SIGNING PERMIT APPLICATiOR <br /> i, (signature of C-67 licensgd authorhad representailve), <br /> hereby authorize(print nam&) to <br /> sign tills San Joaquin County Well&Boring Permit Application on my behalf. t understand this authwwi�&Uon <br /> is valid for oris year and is limited to the work plan detect on the front page of this appilcation, <br /> • CHn29m 07=0 WRLPERMTTAPP -. <br />