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s— <br /> Ban Joaquin County Environmental Health Department <br /> WELL Si BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: / �6 �6ccc� /_71a ��( PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD.) <br /> I hereby affirm that I am licensed under the provisions of Chapter'9 (commencing with Section 7000) of <br /> Division 8 of the California Business arrdr Professions Code and my license Is In full force and effect. <br /> License#: 7--11 aco "a 1 Exp Date: ,__ -7 1201� a <br /> Date: l7tT { U&4-7A <br /> �+& Contr�ayctorCI_ i , <br /> SlgnaturelPjTPtt�Jlftls: i'7P�'k�P12C <br /> Print Name- 0-nnil'.E i7 Lr, 'F WOOL U-0 60.3 � <br /> i <br /> WORKERS'COMPENSATION DECLARATION <br /> 1 <br /> I hereby affirm under periatty of perjury one Of the foilpW rig declarations: (check one) <br /> I have and will maintain a certificate of consent to self-insure for workers' compensation, as <br /> Provided for by Section 8700 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, foe the performance of the work"for Which this permit is issued. My workers` <br /> compensation insurance.carrier and policy numbers ere: i <br /> Carrier. "I Uptl�t hA.43 Policy Number: l�tJ6l��Z6R <br /> I certify that In the pllllllerformanc Ofhe work for which this permit Is Issued, I shall rot employ any <br /> person in any manner so as to become subject to the workers' compensationlaw of California, <br /> And Agree that if T should become subject to workers' compensation provisions of Section 37DO of <br /> the Labor Code, I shall forthwith damply with those pr visions. <br /> Exp bate• I Signature; <br /> Print Name: ('ht'+ r t Dnrra <br /> WARNING:FAiLURE To SECURE wORRER6'cowgNs.AT1oN COVERAGE 19 UNLAWFUL,AND SHALL SUWECT AN EMPLOYER To <br /> CRIMINAL PENALTIES AND CIVIL FINES QP TO $100,000,IN ADDITION TO THS COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,.AND DAMAGES AS PROVIDED FOR IN SECTION 37%OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, f7 1 i 4lY'Clor�c� iK _ (signature of C4V licensed authorized representative), <br /> hereby authorize print name) H,JtO- a ICille, to sign this $an Joaquin County Well & Boring Permit <br /> Application on my behrsif, I understand this authorization Is valid for one year and is limited to the work <br /> plan dated'on the front Pape of this application, <br /> 'EH04907 tl OM2 WL4LPEfApTlWP <br />