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i <br /> San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS: L�U `�L� Il'��t%� S����%���'����c�� LPERMIT SR dt <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> hereby affirm that I am licensed under the provisions of Chapter 0 (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�E: "1 l)(�1 �� Exp Date: <br /> Date: k 0- c 6% \.� Contractor: <br /> Signature: Title: <br /> c <br /> Print Name: 1 .T '? (\lA; L) (A <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:C' 1 ' ` tll� t f'L Policy Number: l.k)o I-)�o 1,Ll c L L•o Y <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: 1(1- \ 1L\ Signature: <br /> l - <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$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 CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C•57 licensed authorized represontative), <br /> hereby authoY ze(print name) , to sign this San Joaquin County Well & Boring Permit <br /> Application oil my behalf. I undorstand this authorization is valid for one year and Is limited to the work <br /> plan dated On the front page of this application. <br /> FIID i9 01 0.`.00112 'dLLL PER:bT AFP <br />