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San Joaquin County Environmental Health Department RE�EIVE <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTdLI <br /> JUN 0 9 2014 <br /> JOB ADDRESS: '413-1 TJ(AA`Yi A IL/3 PERMIT SR# <br /> Ca, e1531-(o ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> LICENSED CONTRACTORS DECLARATION (LCD <br /> hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. <br /> License#: 106;68 Exp Date: 51/3 t JZp IIS <br /> Date: S/z r/ioly Contractor: <br /> . 5 <br /> Signature: ATitle: l� ic�y <br /> Print Name: t j i��'i�\v , �' <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following 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 3700 of the Labor Code, for the performance of the work for which this <br /> permit is issued. <br /> X I 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:ryo. <br /> Carrier: 40+w, "wtkr °s 'Z.a. Co. Policy Number: Cl9l3 <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, <br /> and agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. Date: 10lokA Signature: <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, L -;ZU (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 346 e tyros, to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid for one year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD29-01 Ofi 112 WELL PERMIT APP <br />