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San Joaquin County Environmental Health [Iopar+ment <br /> WELL & BORING PERMIT APPLICATION SUP'I.EMENTAL <br /> JOB ADDRESS: F E EMIT SR# <br /> LICENSED CONTRACTORS DECLA 1R4JION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 9 1 con-mencing with Section 7000) of <br /> Division 3 of the California Business and Professions Code and my Iic :!nsE! is in full force and effect. <br /> License #: �`�CJ� i-xp Date: _.1\L\1 <br /> Date: Contractor: !A <br /> Signature: <br /> Signature: - - Title: _ �,. _ <br /> Print Name: -- <br /> WORKERS' COMPENSATION DECI-XiATION <br /> I hereby affirm under penalty of perjury one of the following declaratic,ns (1-,heck one) <br /> I have and will maintain a certificate of consent to self-ir :u-e for workers' compensation, as <br /> provided for by Section 3700 of the Labor Code, for the pe `o-mance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation insurance, 3E required by Section 3700 of the <br /> Labor Code, for the performance of the work for which Ilii:: Kermit is issued. My workers' <br /> compensation insurance carrier and policy numbe-s are: <br /> Carrier: �-V-1 V\ Policy Null b ar <br /> I certify that in the performance of the work for which this pE rn-it is issued, I shall not employ any <br /> person in any manner so as to become subject to the wore �r3' compensation law of California, <br /> and agree that if I should become subject to workers' COmpE is 3t :)n provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provision-: <br /> Exp. Date: Signature: <br /> Print Name: <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAVI =U1.,,!.ND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION T-: 1 H1: COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 C 1:1 HI: LABOR CODE. <br /> AUTHORIZATIO FOR_ R THAN C-5.r SIGNIN�:i FIE RMIT APPLICATION <br /> l (signature of C-51' li--E ised authorized representative), <br /> hereby authoriz (print name) , to sign this San .la<Ignin County Well & Boring Permit <br /> Application on my behalf. I understand this authorization is valid fc - ono year and is limited to the work <br /> plan dated on the front page of this application. <br /> EHD 29-01 05/09/12 WELL PERMIT APP <br />