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San Joaquin County Environmental Health Department <br /> WELL &BORINGPERMIT APPLICATION SUPPLEMENTAL ,t <br /> JOB ADDRESS: SR c A)e-W"tJ B &A-> �j���ERMIT SR# IJA <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#: C6�6- /2- Exp Date: FL <br /> 3o <br /> __ 9 13 Z01 Contractor: 5- 'C et. � • M � � ✓t <br /> Si nature: C &' sL"Ti�r� O�6G/ <br /> 9 T.1: � '� {� Title: 29 Alcr /7AG <br /> i <br /> Print Name: 5-�-C�42 t) IO A / M u 1p <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 /> 1 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: (; 2✓l -1 (i /� / <br /> Carrier: C7} S7 fid �util � Policy Number: I q O O <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 provision. <br /> Exp. Date: Tl 2..n /S Signature: // <br /> Print Name: e;/—7 4 aZJ <br /> WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> CRIMINAL PENALTIES AND CIVIL FINES UP TO$100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br /> ATTORNEYS FEES,AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AUTHORIZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> 1, (signature of C-57 licensed authorized representative), <br /> hereby authorize(print name) 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 /> Ero z l o 112 wEu PErsNIr ara <br />