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f <br /> San Joaquin County Environmental Health Department <br /> I WELL $ BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> J 0 R `2j)DRESS: O PERMIT SR <br /> LICENSED CONTRACTORS DECLARATION LCD <br /> I hci 1�, affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> I <br /> DivjI;;r.n 3 of the California Business and Professions Code and my license is in full fo ce and effect. <br /> LiCC�nS@ / 7 /00_7? / <br /> Exp Date: <br /> D IF , OL7 Contractor: 00001, 2 <br /> Signpiure: c <br /> Title: <br /> Pr+rlt t'rarne: <br /> WORKERS' COMPENSATION DECLARATION <br /> I 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' compensationas <br /> , <br /> provided for by Section 3700 of the Labor Code, for the performance of the work for which <br /> ipermit is issued. this <br /> have and will maintain workers' compensation insurance,u ante, 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 /> j Carrier: /��tLW,-�`� Po icy Number: 0(1 _10/30DOO e� <br /> certify that in the performance of the work for which this permit is issued, I shall not employ any <br /> .)erson in any manner so as to become subject to the workers' compensation law of California, <br /> :ind agree that if I should become subject to workers' compensation provisions of Section 3700 of <br /> ,he Labor Code. I shall forthwith comply with those prov* ions. <br /> Exp. Date:_ �� / /�1Q/ Signature: <br /> I <br /> Print Name: n �; (/)/A"- <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 /> I` -- (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) 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 /> r� <br /> ':VEL L FERI.II T AP <br />