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Y ' <br /> � F <br /> EHD20.0107/20/10 WELL PERMIT APP - I <br /> San Joaquin County Environmental Health Department h <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> c� �/ f, c 00 ( mob 3 <br /> JOB ADDRESS: or 7O!/ 1 W• Mare(��hP S �`701 PERMIT SR# bc�'63�"- <br /> G <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 Business and Professions Code and my license Is in full force and effect. <br /> License#: EExp�Date: da,:/ // . <br /> Date: 1012-w Contractor: <br /> Signature: Title: <br /> Print Name:`//�s �L///d� s <br /> f <br /> WORKERS'COMPENSATION DECLARATION I <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) <br /> r <br /> 2K 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._ =2nx 1 1 Polley Number: 89/4 , 0y 1 <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, and <br /> agree that if I should become subject to workers'compensation provisions of Section 3700 of the <br /> Labor Code,I shall forthwith comply with those provisions. <br /> Exp. Date' ///z Signature: <br /> Print Name: ,-- <br /> WARNING: <br /> -WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,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 3708 OF THE LABOR CODE. <br /> i <br /> AT OR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-$7 licensed authorized representative), <br /> hereby aut torize(print name) &G1 B- r7�j VA ( to <br /> sign this San Joaquin County Well&Boring Permit Application on my behalf. I understand this authorization <br /> Is valid for one year and Is limited to the work plan dated on the front page of this application. <br /> EH[WM WRN10 W MPMWTAPP yy� <br /> F <br /> I <br />