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EHD 29.01 071,0110 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> �/W�ELL r& BORING <br /> �P�ERMI IT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 1 1 llio✓'f"h %11a,i L %Y-e—J— �-Ur.Y�1 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 Business and Professions Code and my license is in full force and effect. <br /> License#: L `5- -oo �y ExpDate: D V 1l 31?j 1�f <br /> Date: /G/ 3 d p /Z Contractor: C. NUpf'd 1114 �VUGe.S <br /> Signature: _ r Title: <br /> Print Name:il )Ir-AJ Xs1 C� i <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 /> �✓ 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 <br /> , insurance carrier and policy numbers are: <br /> Carrier: 64-O -C�Jr"J &-In� JFNSuw c-Policy Number. 60073(3 <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, and <br /> agree that if I should become subject to workers' compensal ipif provisions of Section 3700 of the <br /> Labor Code, i shall forthwith comply with those provisions. /f <br /> Exp. Date: Signature: <br /> Print Name: c� 2.i� 'f.) 0 L/ <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 3708 OF THE LABOR CODE. <br /> } AUTHORIZZA-TIONf�/QR TER THAN C-57 SIGNING PERMIT APPLICATION <br /> vvrl C> 7 �!/ - (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) ,to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization <br /> is valid for one year and is limited to the work plan dated on the front page of this application. <br /> EHDZ I07!30110 WELL PERMIT AWP <br />