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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: �5 X45 I I�lci� S (�� <br /> --� c--�I^ _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 /> DiVlsion 3 of the California Business and professions Code and my license Is in full force and.effact. <br /> License.#: loaGrii Exp Date: 5 3( G'S <br /> Date:_ \ I)�l I1,01S i <br /> Contractor: <br /> Signature: �� 1 �1 ' Title:_ <br /> Print Name: <br /> W RKERS' 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 /> Labor Code, for the performance of the work for which this permit is Issued. <br /> I have and will maintain workers' compensation Insurance, as required by Section 3700 of the <br /> I <br /> compensation Insurance carrier and policy numbers are: My workers' <br /> tiL <br /> Carrier; cWA017_j Policy Number: _ rZ�l)E�� � _99-h <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 d should become subject to workers'compensation provisions of Section 3700 of <br /> the Labor Code, I shall forthwith comply with those provisions. <br /> Exp. bate: Signature: —1/16 1 <br /> I 4 �n <br /> Print Name: RtI191I `/O 1��rSa <br /> WARNRJG:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER t0 <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 COME. <br /> nnAUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), I <br /> hereby a thorize(print name) JLl KuL.dPEL , to sign this San Joaquin County Well & Baring 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 /> EHDA801 ONOW2 <br /> WELL PERMIT APP III <br />