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San Joaquin County Environmental Health Department <br /> WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: Z 2''l 14 /�'A"Y tP"S" IL d PERMIT SR# <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 licenselis in fu l force and effect. <br /> License #: r �JU Exp Date. <br /> Date: ontractor: v <br /> V1 <br /> Signatur l� V _ Title: <br /> Print Name: <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 /> compens 'on ins uran carrier a policy numbers are: <br /> y z <br /> Carrier: k-��� Pollc Number: H <br /> I certify that in the performance of the work for which this pprrmit is issue I shall not employ any <br /> person in any manner so as to become subject to the w rkers' compensation law of California, <br /> and agree that if I should become subject to workers' com nsation proui'sions of S tion 3700 of <br /> the Labor.Cod , I shall forthwith comply with those Irovi on <br /> Exp. Date: �L Signature: ` <br /> Print Name: c( 1 I vu <br /> WARNING:FAILURE Tn CURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENA TIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEY'S F S,AND DAMA S PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> A STH ZEITION FQR O ER THAN C-57 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> 1 <br /> hereby autho ze�(pnname) to sign this San Joaquin County Well & Boring Permit <br /> Application on my behalf. 1 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 /> EH6::8-01 )F091E <br /> �':ELL PEiiGIT APP <br />