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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS: `arch Zcy_�,__TPac _ CA 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 force and effect. <br /> q .. <br /> License#: ._1�?/ -5(0 416 — — - --- Exp Date: f0 ��..t._ �_L� ,__- ------- <br /> Date: f�?/1� _ __� Contractor:,_Va�orial1— _ .--- <br /> Signature: T Title: <br /> Print Name: �.i ACS i> ( 7 AL It 0 tk - <br /> WORKERS' COMPENSATION DECLARATION <br /> I <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 /> 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 /> Carrier:—Zi—Iric� N of tGt1 ._�_ Policy Number. <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 provision <br /> Exp. Date: ��! j� ------ Signature: <br /> // <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 /> AAUTT TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> � tn�_ (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name)5 C! r 4 to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 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 /> WELL PERMIT MP <br /> ENO 2i01 ISIOBnY <br />