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San Joaquin County Environmental Health Department <br /> MI <br /> WELL& BORING PERT APPLICATION SUPPLEMENTAL <br /> J013 ADDRESS: 2G0 '3. -^"%"" S"c PERN51T SIR# <br /> V%*�- Wcivv I C,p, <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#;: 1 0 5 C a`_ Exp Date: D! " 3 1 • I <br /> Date' V t 11 Contractor.- V I t o nt� <br /> Signature: Title' <br /> Print Name: (, r)wika trn�tfYkt�'fil <br /> WORKERS'COMPENSATION DECLARATION <br /> i hereby ffirm under penalty of perjury one of the following declarations:(check one) <br /> 'f 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 /> ,,ampenaation insurance carrier and policy numbers are. <br /> Cartier: 4�olicyNurnlaeri <br /> 1 Certify that in the performance of the work forwhich 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"Sectton 3700 of <br /> tiie Labor Code,i shall forthwith comply with those pr? ions. <br /> r } <br /> Exp.T1ate: Signature., <br /> Print Name: (A cf n DOmOln-h <br /> WARNING:FAILURE TO.SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES ANO.CfVIL 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 M LABOR CODE, <br /> AUTHOR ATION FO OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> lA,1 rA <br /> _(signature of C-i5T licensed authorized representative), <br /> hereby au orize(print name) s t,l. ., to sign this San Joaquin,County Well & Boring Permit <br /> Application on my behalf, t 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 /> arta zsi ar airza!+n WICu PERMr AMI <br />