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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOBADORESG� <br /> � PERMIT SR <br /> LICENSED CONTRACTORS DECLARATION <br /> | hereby affirm that | am licensed under the provisions o/Chapter Q (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 /> License#1 7209 1 1 <br /> Expiration Date: 4/30/2020 <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm Linder penalty of perjury one of the following declarations: (check one) <br /> [] | have and will maintain o certificate ofconsent to se|Annurefor workers' compensation, as <br /> p/nvidedfo/ by8eution37O8ofthmLaborCode. fortheperfornnanceofthewnrkfurwhiohthis <br /> permit iaissued. <br /> | have and will maintain workers' compensation insurance. as required by Section 3700 of the <br /> Labor Code, for the performance ofthe work for which this permit isissued. My workers' <br /> compensation inuu/ancocarrier and policy numbers are: <br /> Carrier: State Fund policy #: S115O22-1S Exp. Date: 10/2/2020 <br /> | certify that in the rfof the <br /> any manner so as to become subject to/the workers' c rn s a t.on law of California, and agree that if I <br /> so <br /> should become subject to worker,' cmensation provisio Section 3700 of the Labor Code, I shall <br /> �rthwiih comply with thlo provisions. <br /> Z,-- ;A y <br /> WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL <br /> SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN <br /> ADDITION TO THE COST OF COMPENSATION, INTEREST, ATTORNEY'S FEES, AND DAMAGES <br /> AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 4C <br /> to sign this San Joaquin Couln� <br /> Borl),)g Permit Application on my behalf, I understand this <br /> auznonoao/on /svaoUfor <br /> one ye page mfthis application. <br />