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EHD2& 1 07/"MO WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL&BORING PERMIT APPLICATION SUPPLEMENTAL <br /> ,Gg0o , 5G Imo, /s�tis, s� s�, sties, 53x3, 53570 <br /> JOB ADDRESS: 5 G��l0 PA C r fzG AvfT"G 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 Business and Professions Code and my license is In full force and effect. <br /> License#: Liss 16 5 Exp Date: 113 / <br /> 1 i 1Z <br /> Date: 12 /� _Contractor: CitZ(hfa baxwsuuGl <br /> Signature: Title: Qp�Yj�/G�l� /�n�W4w <br /> Print Name: <br /> f <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 /> I compensation insurance carrier and policy numbers are: ; <br /> C� – / r I <br /> Carrier. lea✓/ / Policy Number.D���Q2b I( <br /> I certify that in the performance of the work for which this permit Is issued, l 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 1f 1 should become subject to workers'compensation provisions of Section 3700 of the' <br /> Labor Code,I shall forthwith comply with those provisl <br /> Exp, Date: �3/ Z signature: Z/��Zi04—j <br /> Print Name: X 1700 //'C/fi.�' <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUEIJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CML FINES UP TO$100,000,IN ADDITION TO THE COST OF COMPENSATION,INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 7708 OF THE LABOR CODE. <br /> �iZAL19N FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> __._. _I, ��*..— _(s.fgnature of C�67 licensed authorized representative), <br /> hereby authorize(print na mei ,to <br /> sign this San Joaquin C ounty,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. j <br /> EHD 2401 0]20110 MLLPEEMITAPP <br />