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M <br /> WELL PERMrr APP <br /> EHD 29-01 07/20/10 <br /> San Joaquin County Environmental Health Department <br /> Fof <br /> ELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ADDRESS: 1 Hr01 r x-.y. 1 t A� a P a) "aR1 H gut PERMIT SR 9 <br /> LICENSED CONTRACTORS DECLARATION (LCD) <br /> m that 1 am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br /> the Business and Professions Code and my license is in full force and effect. <br /> SExp Date:Contractor:gL- - Title: Sc t1 �l <br /> Fh�� t3. �.' X <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. n <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• VW VXA4 T�v"�-�u Policy Number: <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'd 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: Signature: 1 <br /> Print Name: <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE Is UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3703 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1 l (signature of C-4711cenaad authorized representative), <br /> hereby at horize(print name) r e /'eUcp n PADIC us to <br /> sign this San Joaquin County Well 3 Boring Permit Application on my behalf. 1 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 /> VIFll PERMR APP <br /> EHD 2B OMWO <br />