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s V <br /> ON AJ-D <br /> Son Joaquin County Environmental Hoxltih Doparhnoat <br /> WELL&BORING PERMITAPPLICATIONSUPPLEMENTAL <br /> JOB ADDRESS: � W. k1Ar'ck L401 t Si'1 k'i PERMIT SR It (0 <br /> LICENSED CONTRACTQRS DECLARATION (LCD) <br /> t hereby affirm that I am licensed under the provisions of Chapter 0(co nmonclnfr with Section 7000) of <br /> Division 3 of the California Business rind Professions Code and my license Is In full forte atul effect. <br /> License it; � � `r Exp Rate: <br /> Contractor,lAlbOrkt-t) <br /> slgntlturo; ztaiw9l,u i i r1 Title: ` A�+�i rl p ^ <br /> PrintNamw Qr!�NNa`f\k ..2 <br /> WORKERS' COMPENSATION DECLARATION <br /> hereby affirm undor penally of perjury ono of the following declarations;(ohock one) <br /> I h1vo and will malnlain a codiflaata of consent to self-IMUM for Workers' compensation, as <br /> provided for by Secllon 3700 of the Labor Code,for the performance of the work for which tills <br /> pofmit Is Issued. <br /> I have and will (maintain workers' compensation,Insurance, as required by section 3700 of the <br /> Labor Code, for the perfonnaneo.of the work for which this permit Is issued. My 'wwkors' <br /> compensation Insurance carrier and polity nunrgers era; <br /> Carrlor: ¢--�U Gla - Policy Numbor: nglLAa40.-9D� <br /> I certify that In the performance of the work for which this panmiL Is Issued, I shall not employ tiny <br /> person In any manner so as to become subjoct to the workers' comparlsation law of California, <br /> and agnea that If I shoUld bocome subject to workers'compensnlion provisions of Section 3700 of <br /> the Labor Code, i shall forthwith comply with thoso provisions, <br /> Exp.Date; XD - 1- t`�_ Signaturo: <br /> Print Name: rtl+�`c�gL_� IJtx�c�u]ac� <br /> WANNINO:PAILUaE TO SPGVRE WORKERS'COIAPENSATION COvemoc 18 UNLAWFUL,Alto SHALL SUBJECT All UMPLOYER TO <br /> CRIMINAL PIiNALTIES ANO CMI.FINES UP TO$fo0,000,IN ADDITION TO THE COST Or COMPENSATION.INUMMT, <br /> ATTOaNEY'S FNais,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OP Tlla LABOR CODE, <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> I, , lJAis t1 W w���� (signature of C-67 Ilconsod nuthorizod roprosontativa), <br /> hereby aunI <br /> thor a(print na <br /> o) XSlf;Vw114 .,, to sign title San Joaquin County Woll & Borhhg Permit <br /> Application on my beholf. I undorstond this authorization la valid for ego year.and Is limited to the work <br /> plan dotod on(Ito front patio of this application, <br /> aronaur tannate vcuPar:wrnrr <br />