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San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: 344/ri Cast lYla;H Sf ✓��7JsKfD►1.� (,"}. 9S�O-VERMIT SR # <br /> LICENSED CONTRACTORS DECLARATION (LCD} <br /> I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000 <br /> Division 3 of the California Business and Professions Code and my license is in full force and effect. ) of <br /> License#: e-5 8 $359 <br /> Exp Date: <br /> Date: Contractor: *�L l<181_L �vAONNr�c�j— <br /> Signature: �` <br /> Title: Vzo�_ i rl o lam+ <br /> Print Name: x(38 ,;L.44 <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 insurance carrier and policy numbers are: <br /> Carrier: <:::Afa r1 A Pollicy Number: <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:- t <br /> Signature: <br /> Print Name: `S iro ►t <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE 13-UNLAWFUL <br /> ,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 3706 OF THE LABOR .ODE. <br /> AUTHO <br /> : . T R THAN C-57 SIGNING PERMIT APPLICATION <br /> I' (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) R-lYr 47j J qjrV , to sign this San Joaquin County Well & Boring Permit <br /> Application on 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 /> EHD 29.01 05/09/12 <br /> WELL PERMIT APP <br />