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j;lr <br /> San Joaquin County Environmental Health Department <br /> p WELL& BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: PERMIT SR# <br /> LICENSED CONTRACTORS DECLARATION (LCD) y: <br /> Al <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: /L3IZ-1 <br /> Date: f/� ,� Contractor: <br /> Signature: Title <br /> Print Name: l Li/ice P�/Uf7�d^ <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the fallowing declarations: (check one) <br /> Ji <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: A ^/°y Policy Number: 19161fWlll''firI <br /> r. <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. F <br /> Exp. Date: g 41// Signature: <br /> Print Name: <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, <br /> ATTORNEY'S FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE. <br /> > <br /> T RI TION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> i <br /> (signature of C-57 licensed authorized representativo� f <br /> hereby authorize(print name) to sign this San Joaquin County Well 8..Boring Permi'. <br /> - Application on my behalf. I understand this authorization Is validfor one year and is Limited to the work' { <br /> plan dated on the front page of this application. <br /> Ewo zam owsnz Wak.ru AT> -a;i. <br />