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EHD 29-01 07!20!16 WELL PERMIT APP <br /> San Joaquin County Environmental Health Department <br /> WELL & BORING PERMIT APPLICATION SUPPLEMENTAL <br /> JOB ADDRESS: ' ' .1 t . JL01 C. : Z ERMIT 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#: �GJrj -xp Date: <br /> Date: `� > 1 Contractor: I 4 <br /> Signature: _— Title: � t fLI-1 PI1� <br /> Print Narne <br /> WORKERS' COMPENSATI(:)N 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, fc:,r the performance of the work for which this <br /> permit is issued. <br /> I have and will maintain workers' compensation in::,urance, 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 <br /> and policy numbers are: <br /> Carrier: L SLA Lf F Q `� `� Policy Number. <br /> 1 certify that in the performance of the work for wh ch 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 if 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: } 2J 1 I '��`31 Z _ Signature: . <br /> -... <br /> PrintName: . -- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERA(6 E IS UNLAWFUL,AND SHALL SUBJECT AN EMPLOYER TO <br /> --� CRIMINAL PENAL TIES ARD CIVIL FINES UP To$100,000,IN AODMON TO THE COST OF COMPENSATION,INTEREST, <br /> _, ), T7ORNEY S FEES,AND DAMAGES AS PROVIDED FOR IN SLCTION 3706 OF THE LABOR CODE, <br /> AUTHORI O?1 €OR OTHER THAN C-5'7 SIGNING PERMIT APPLICATION <br /> (signature of C-57 licensed authorized representative), <br /> hereby authorize (print name) , to <br /> sign this San Joaquin County 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. <br /> EHO 29-01 0irMi] WELL PERMIT APP <br />