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i San Joaquin County Environmental Health Department <br /> [ WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> I <br /> JOB ADDRESS: 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 license is in full force and effect. <br /> License#: GS 7 Exp Date: Lx/Z/� <br /> Date:_C l/ ,! --Contractor: <br /> Signature: Title: <br /> Print Name <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (check one) �l <br /> ^/^/ r. K <br /> X 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: �f <br /> Carrier: e9�lneel Policy Number: WWII <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any Gi <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: 5'�// Signature: <br /> Print Name:_ eG <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TQ' <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, I' <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> ti <br /> HJT Rl" TION FOR OTHER THAN C•57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative{ <br /> herebyauthorize ) <br /> (print .ft£ fi:'to sign this San Joaquin County Well &_Boring Perm , <br /> Application on my behalf, I understand this authorization Is valid for one year and is limited to the work , <br /> �IC <br /> pian dated on the front page of this application. <br /> EMD� USRI^_(i3 WELL mwrAr,,. <br /> t I� <br />