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San Joaquin County Environmental Health Department <br /> gWELL'& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> .JOB ADDRESS: l3� Sou ovo pbctCyow PERMIT$R# <br /> i <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 /> License#: 4 a6 SA Exp Date: S j3(1 aoi 5 <br /> Date: ) but,1-),O( C Contractor: -TT-G <br /> Signatute: -1 F�L-1VE Title: AIC-Qv, <br /> Print Name: <br /> WORKERS'COMPENSATION DECLARATION <br /> I heraby affirm under penalty of perjury one of the following declarations: (check ate) <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 /> X 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 /> compensayrition insurance carer and policy numbers are: <br /> Carrier: CIq �Coj Policy Number: 3-)L0T-(-„tBCk-41 <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 provisions. <br /> Exp. Date: Signature: 1%, c <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$1110,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, '. <br /> ATTORNEY'S:FEES,AND DAMAGES AS'PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> i <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby Authorize(print name) kin Ki,je f , to sign this San Joaquin County Well & Boring Permit <br /> Application un my behalf. I understand this authorization is valid for one year and Is limited to the work <br /> plan dated on the front page of this application. <br /> EHM 2M10$Nfy11. WELL PERMIT APP i <br />