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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ?Ori_ D r S&&7� n 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 3 Of the California Business and Professions Code and my license is in full fo ce and effect. <br /> License #: 7- / IOD Exp Date: '7 3/ -LOIS <br /> I <br /> DatedL7 / Contractor: l.�GbDUDIAe- Y <br /> Signature: , A <br /> Title: i'�S�,Qn <br /> Print Name: �OO� <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 /> .)ermit is issued. <br /> i <br /> 0-40/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: <br /> I <br /> j Carrier: 0 &eApdiy Number: OG -q0l30000 g <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 prov' ions. <br /> Exp. Date: 1011-Z,2-01 Signature: <br /> Print Name: �n C.'(�Z, C , W6 oc6j± <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO 5100,000. 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 /> i <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) to sign this San Joaquin County Well & Boring Permit <br /> Applica6ml 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 /> rN <br /> WELL FER611T APP <br />